Exercise-electrocardiography stress testing provides excellent negative predictive value for screening hypertensive patients, while imaging stress-echocardiography is warranted for positive cases.
What is the optimal diagnostic strategy for identifying myocardial ischemia in hypertensive patients?
In hypertensive patients, exercise-ECG is an effective initial screening tool due to its high negative predictive value, while stress-echocardiography is recommended for positive or ambiguous cases to accurately identify epicardial CAD.
Arterial hypertension can provoke a reduction in coronary flow reserve through several mechanisms that are not mutually exclusive (i.e. epicardial coronary artery disease (CAD), left ventricular hypertrophy and structural and/or functional microvascular disease). These different targets of arterial hypertension should be explored with different diagnostic markers. In fact, stress-induced wall motion abnormalities are highly specific for angiographically assessed epicardial CAD, whereas ST segment depression and/or myocardial perfusion abnormalities are frequently found with angiographically normal coronary arteries associated with left ventricular hypertrophy and/or microvascular disease. Exercise-electrocardiography stress test can be used to screen patients with negative maximal test due to its excellent negative predictive value, which is high and comparable in normotensives and hypertensives. When exercise-electrocardiography stress test is positive (or uninterpretable or ambiguous), an imaging stress-echo test is warranted for a reliable identification of significant, prognostically malignant epicardial CAD in view of an ischemia-guided revascularization.
Picano et al. (2001) conducted a review in Hypertension and myocardial ischemia. Exercise-electrocardiography and imaging stress-echocardiography was evaluated. Exercise-electrocardiography stress testing provides excellent negative predictive value for screening hypertensive patients, while imaging stress-echocardiography is warranted for positive cases.
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