BioMed Cen al
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Ca dio ascula Ul asound
Open Access
Resea ch
Exe cise-induced in a- en icula g adien s as a equen po en ial
cause o myoca dial ischemia in ca diac synd ome X pa ien s
Ca los Co im*1,3, Ana G Almeida2 and Manuel Ca age a1,2,3
Add ess: 1Ca diology Depa men , Ga cia de O a Hospi al, Almada, Po ugal, 2Ca diology Depa men , San a Ma ia Hospi al, Lisboa, Po ugal
and 3Lisboa Uni e si y Medical School, Lisboa, Po ugal
Email: Ca los Co im* - ca losad[email p o ec ed]; Ana G Almeida - anagalme[email p o ec ed];
Manuel Ca age a - mca age a@mail. elepac.p
* Co esponding au ho
Abs ac
Backg ound: The de elopmen o in a- en icula g adien s (IVG) du ing dobu amine o exe cise s ess
is no in equen , and can be associa ed o symp oms du ing s ess.
The pu pose o his s udy was o assess he occu ence o IVG du ing exe cise s ess echoca diog aphy
in ca diac synd ome X pa ien s.
Me hods: We p ospec i ely e alua ed 91 pa ien s (p s) mean aged 51 ± 12 yea s (age anged 20 o 75
yea s old), 44 o whom we e women. All p s had angina, posi i e exe cise ECG eadmill es ing, no mal
es echoca diog am and no co ona y a e y disease on co ona y angiog am (ca diac X synd ome). A e
comple e Dopple echoca diog aphic e alua ion wi h de e mina ion o le en icula ou low ac index
(LVOTi), ela i e le en icula wall hickness (RLVWT) and le en icula end-dias olic olume index
(LVDVi), all pa ien s unde wen s ess echoca diog aphy wi h wo-dimensional and Dopple echog aphic
e alua ion du ing and a e eadmill exe cise.
Resul s: Fo analysis pu pose pa ien s we e di ided in 2 g oups, acco ding o he de elopmen o IVG.
Dopple e idence o IVG was ound in 33 (36%) o he pa ien s (G oup A), wi h mean age 47 ± 14 yea s
old (age anged 20 o 72 yea s) and wi h a mean end-sys olic peak g adien o 86 ± 34 mmHg ( anging om
30 o 165 mmHg). The IVG de elopmen was accompanied by SAM o he mi al al e in 23 p s. Th ee o
hese p s expe ienced symp oma ic hypo ension. Ten we e women (30% p s). 58 p s in g oup B, 34 o
whom we e women (59%) (p = 0,01 s g oup A), mean aged 53,5 ± 10,9 yea s old (age anged 34 o 75
yea s) (p = 0,03 s g oup A), did no de elop IVG. LVOTi was 10,29 ± 0,9 mm/m2 in g oup A and 11,4 ±
1 mm/m2 in g oup B (p < 0,000); RLVWT was 0,36 ± 0,068 in g oup A and 0,33 ± 0,046 in g oup B (p <
0,01); LVDVi was 44,8 ± 10 ml/m2 in g oup A and 56 ± 11,6 ml/m2 in g oup B (p = 0,000).
Conclusion: 1. A signi ican numbe o pa ien s wi h ca diac X synd ome de eloped IVG du ing up igh
exe cise in eadmill. These p s (g oup A) a e mainly males and younge han hose who did no de elop
IVG.
2. The de elopmen o IVG and mi al al e SAM on exe ion seems o be associa ed wi h ST segmen
downsloping du ing s ess es ing in pa ien s wi hou epica dial co ona y disease.
3. The de elopmen o IVG and mi al al e SAM seems o be associa ed wi h lowe LVOTi, lowe LVDVi
and highe RLVWT.
Published: 14 Janua y 2008
Ca dio ascula Ul asound 2008, 6:3 doi:10.1186/1476-7120-6-3
Recei ed: 10 Decembe 2007
Accep ed: 14 Janua y 2008
This a icle is a ailable om: h p://www.ca dio ascula ul asound.com/con en /6/1/3
© 2008 Co im e al; licensee BioMed Cen al L d.
This is an Open Access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion License (h p://c ea i ecommons.o g/licenses/by/2.0),
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Backg ound
The de elopmen o IVG du ing DSE has been la gely
epo ed and his ac is commonly associa ed wi h symp-
oms du ing he s ess s udy [1,2]. The occu ence o IVG
du ing he ESE is a ely ind [3]. In a g oup o 10 pa ien s
who de eloped IVG du ing DSE, we pe o med ESE and
we ound a small IVG in only one o hem [4]. In a 23
yea s old male, wi h a posi i e eadmill es , a s uc u al
no mal hea , no mal co ona y angiog aphies, an ESE was
pe o med and du ing he s udy we unexpec edly de ec a
102 mmHg in a- en icula g adien [5] and sys olic
an e io mo emen o mi al al e (SAM). A simila case
has been epo ed p e iously by Lau [6] and was ea ed
success ully wi h β blocke s.
The aim o his s udy was o p esen he esul s o sea ch
o in a- en icula g adien s du ing exe cise s ess
echoca diog aphy in pa ien s wi h angina, posi i e s ess
elec oca diog aphy, no mal co ona y a e ies, and no -
mal echoca diog am (ca diac X synd ome).
Me hods
This s udy includes 91 (p s) mean aged 51 ± 12 yea s (age
anged 20 o 75 yea s old), 44 o whom we e women. All
p s had angina, posi i e exe cise ECG eadmill es ing
( ou pa ien s had only ischemia in a myoca dial pe -
usion s udy), no mal es echoca diog am – no le en-
icula hype ophy – and no co ona y a e y disease on
co ona y angiog am. Diabe es melli us o uncon olled
hype ension in he las yea we e mo i es o exclusion.
Twen y ou pa ien s (26%) a e cu en smoke s and hi y
h ee p s (36%) had hype choles e olemia.
A he momen o inclusion in he s udy, 47 (51%)
pa ien s we e ea ed wi h ni a es, 10 (11%) wi h calcium
an agonis s, 18 p s (20%) on β blocke s, 12 p s (13%)
wi h angio ensin II ecep o blocke s o angio ensin-con-
e ing enzyme inhibi o s, 7 p s (8%) wi h diu e ics.
All pa ien s ga e in o med consen o he s udy.
Exe cise s ess echoca diog aphy
A e comple e echoca diog aphic e alua ion which also
includes de e mina ion o le en icula ou low ac
index (LVOTi), ela i e le en icula wall hickness
(RLVWT) and le en icula end-dias olic olume index
(LVDVi), all pa ien s unde wen s ess echoca diog aphy
wi h wo-dimensional and Dopple echog aphic e alua-
ion. We also measu ed he dis ance D1 in he end o dias-
ole, in sho axis iew, as showed in Figu e 1. Exe cise
s ess echoca diog aphy as pe o med by he au ho s [7]
includes e alua ion du ing all he exe cise in eadmill, o
con ac ili y, and in his g oup o pa ien s also pulsed,
con inuous and colou Dopple om apical window
(Addi ional Files 1 and 2). Mi al al e mo ion was also
assessed, o he de elopmen o SAM (Addi ional ile 3
and Figu e 2). The exam was o ally s o ed in ideo ape
and pa ially in op ical disk. A signi ican in a en icula
g adien , was conside ed an inc ease in he in a en icu-
la low eloci y o o g ea e han 2.5 m/s a he end o
sys ole ( elesys olic peak)(Figu e 3) and i s occu ence
sepa a ed he pa ien s in wo g oups.
S a is ical analysis
The esul s a e exp essed as mean ± SD o con inuous a -
iables, and equency pe cen age o ca ego ical a iables.
The a iables we e compa ed be ween g oups wi h he s u-
den T es . The X2 es was used o quali a i e a iables.
Resul s o s a is ic es s we e conside ed signi ican i he
obse ed p alue was less han 0.05.
Resul s
A ypical example o s ess elec oca diog aphy (Figu e 4),
and angiog aphic (Figu e 5) indings is showed.
F om he all g oup, 33 pa ien s (36%) de elop IVG (g oup
A) and 58 p s (64%) did no de elop in a en icula g a-
dien (G oup B) as de ined by he au ho s. In g oup A he
IVG a peak exe cise was 86 ± 34 mmHg ( anging om 30
o 165 mmHg).
In all bu 11 pa ien s, 85% o p edic ed maximum heo-
e ical hea a e o age was eached. Clinical and demo-
A line ha o igina es a he poin whe e he in e io wall begins, di ides he le en icle in hal sFigu e 1
A line ha o igina es a he poin whe e he in e io wall
begins, di ides he le en icle in hal s. The D1 dis ance is
he dis ance be ween ha line and he pos e o in e nal papil-
la y muscle (a ow) a he poin whe e i encoun e s he
in e io wall.
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g aphic da a is p esen ed in Table 1, de ails o he exe cise
es a e depic ed in Table 2, and de ails o echoca diog am
in Table 3, 4, and 5.
In g oup A 23 p s (70%) de elop SAM (Figu e 2, Addi-
ional ile 3) du ing exe cise, associa ed wi h IVG (Figu e
3, Addi ional ile 2). No one pa ien de eloped segmen al
wall abno mali ies.
Mul i a ia e Analysis
A logis ic eg ession model was cons uc ed wi h he ol-
lowing a iables: age, sex, e o angina, le en icula
ou low ac index, le en icula dias olic olume
index, ela i e wall hickness, le en icula mass index,
D1 dis ance. F om he a iables included a ained s a is i-
cal signi icance (p < 0.05) he con ibu ion o e o
angina, D1 dis ance, LVDVi, LVOTi and sex, o appea -
ance o IVG as we can see in Table 6.
Discussion
Pa ien s wi h a posi i e eadmill exe cise es , and no mal
co ona y angiog aphy ha e long been ecognised as an
impo an p oblem in clinical p ac ice [8-10]. These ea ly
s udies iden i ied many o he cha ac e is ics o wha was
subsequen ly cha ac e ized as synd ome X [10]. The same
denomina ion was also applied o a synd ome, cha ac e -
ized by insulin esis ance, hype insulinemia, and diabe-
es, ha is associa ed wi h dyslipidemia, hype ension,
and abdominal obesi y. Hence a mo e speci ic e minol-
ogy comes in use: angina wi h no mal co ona y a e iog-
aphy [11]. Pa ien s wi h his en i y, p edominan ly
women [12], complain o pain ha is equen ly a ypical.
I may be p ecipi a ed by exe ion, al hough he h eshold
o p ecipi a ing pain is highly a iable [13]. I s du a ion
may be uncha ac e is ically long, and i may be unusually
se e e and is a ely associa ed wi h symp oms such as dia-
pho esis. Pe usion abno mali ies ha e been obse ed
commonly in pa ien s wi h ches pain and no mal co o-
na y a e iog ams, bu no consis en co ela ion could be
made among he ex en o he de ec , he posi i i y o he
exe cise es , and exe cise ole ance [14]. Thus in many o
his pa ien s he e is e idence o pe usion abno mali ies
ha a e a ibu ed o abno mali ies in he mic o ascula-
u e [15]. Howe e s ess echoca diog aphy allways ailled
o demons a e segmen al wall abno mali ies e en show-
ing hype dinamic en icles[16].
The esul s o ou s udy, in which 33 (36%) o 91 pa ien s
wi h no mal co ona y angiog am and posi i e eadmill
exe cise es de eloped in a en icula g adien , sugges
ha ST-segmen dep ession may be ela ed wi h he de el-
opmen o IVG du ing exe cise which is possibly in ol ed
in he genesis o elec oca diog aphic changes. The possi-
ble associa ion be ween ca díac X synd ome and he
de elopmen o IVG du ing exe cise was desc ibed be o e
[17,18] howe e some o he pa ien s om hese s udies
ha e a e ial hype ension, and le en icula hype o-
phy ha by de ini ion o X Synd ome [19] we ha e
excluded and ha mo e equen ly de eloped IVG [3].
The low ob ained a ha momen wi h con inuous Dopple Figu e 3
The low ob ained a ha momen wi h con inuous Dopple .
In his apical ou chambe iew ob ained nea peak exe cise (be o e s oping) we can clea ly see sys olic an e io mo e-men o mi al al eFigu e 2
In his apical ou chambe iew ob ained nea peak exe cise
(be o e s oping) we can clea ly see sys olic an e io mo e-
men o mi al al e.
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The appea ance o IVG in ou s udy was associa ed wi h
mo phological de e minan s like educed LVOTi, educed
le en icula dias olic olume, a educed dis ance D1,
and inc eased ela i e le en icula wall hickness. All
hese inding ansla e a p opo ional small hea ha he
mul i a ia e model con i ms.
The educed D1 in G oup A means an an e io "displace-
men " o he pos e o in e nal papilla y muscle ha may
be in ol ed in he de elopmen o IVG and SAM o he
mi al al e [20,21] as desc ibed by o he au ho s.
We can admi ha his phenomenon is e en ually caused
by he sub le changes in le en icle geome ic shape and
dimensions wi h mo e an e io papilla y muscles implan-
a ion [20,21], ha du ing exe cise, induce and submi he
co dae and mi al al e o an abno mal sys olic an e io
mo ion and o papilla y muscle ischemia. The obs uc ion
o he ou low in le en icle wi h he inc ease in he
in a en icula p essu e ha i causes may con ibu e, o
le en icula s ain and ST-dep ession in his pa ien s.
The de elopmen o in a en icula g adien du ing exe -
cise may possibly explain he ST changes in a subg oup o
pa ien s who ha e eadmill posi i e es and no mal co -
ona y a e ies.
The pa ien s wi h IVG du ing exe cise had mo e angina
du ing exe cise and we e p edominan ly male, and his
may explain why hese pa ien s we e submi ed o co o-
na y angiog aphy much ea ly, a e he beginning o he
symp ons, han pa ien s in G oup B. F om he all s udy
g oup 42 pa ien s (46%) ep oduced symp oms du ing
ESE, howe e his ac occu ed mo e equen ly (22 p s
om 33 in g oup A s 20 om 58 p s in g oup B – p =
0.002) in g oup A, a ou ing he po encial pa icipa ion
o in a en icula g adien in he occu ence o symp-
oms.
Summa y o a posi i e exe cise s ess es in one pa ien om he s udyFigu e 4
Summa y o a posi i e exe cise s ess es in one pa ien om he s udy.
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In ou s udy popula ion, we ound a g ea numbe o
pa ien s ha de elop SAM o he mi al al e in associa-
ion wi h IVG con a ily o o he au ho s [17,18]. We
hink ha we de ec SAM in a g ea e numbe o pa ien s
because we do echo du ing all he exe cise in eadmill
(Addi ional ile 2 and 4) [7]. The magni ude o he IVG
ha we ha e de ec ed in ou pa ien s is also g ea e o he
same mo i e (Figu e 3).
Fou o he 33 pa ien s ha de eloped in a en icula
g adien a e a hle es [22] and we should p obably s udy
his phenomenon in his speci ic popula ion and, i his
Table 1: Clinical and demog aphic da a
G oup A G oup B p
Age, yea s 47,70 ± 13,36 53,53 ± 10,89 0,026
Sex, emale (%) 10/33 (30%) 34/58 (59%) 0,008
BSA m21,8 ± 0,16 1,73 ± 0,13 0,022
E o Angina 28/33 (85%) 33/58 (56%) 0,006
E o less Angina 9/33 (27%) 35/58 (57%) 0,002
Du a ion o symp oms be o e ca h. (mon hs) 15 ± 10 46 ± 40 0,000
Time o FLW (mon hs) 36,4 ± 17,9 39,1 ± 19,5 0,55
E en s in FLW 6/33 (18%) 8/56 (14%) 0,31
ACS in FLW 1/33 (3%) 7/56 (13%) 0,24
β Bloq. 7/33 (21%) 11/58 (19%) 0,798
CCB 4/33 (12%) 7/58 (12%) 0,666
Ni a es 16/33 (48%) 31/58 (53%) 0,769
IECA/ARAII 5/33 (15%) 7/58 (12%) 0,680
Diu e ics 2/33 (6%) 5/58 (9%) 0,663
β Bloq. FLW 20/33 (60%) 17/56 (30%) 0,003
CCB FLW 4/33(12%) 19/56 (34%) 0,530
Ni a es FLW 9/33 (27%) 33/56 (59%) 0,006
IECA/ARAII FLW 9/33 (27%) 8/56 (14%) 0,068
Diu e ics FLW 4/33(12%) 4/56 (7%) 0,403
BSA – body su ace a ea; ACS – Acu e co ona y Synd ome; CCB – Calcium chanell blocke s; FLW – ollow-up
No mal angiog aphy o co ona y a e ies in he same pa ien Figu e 5
No mal angiog aphy o co ona y a e ies in he same pa ien .

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occu s, also in es iga e he possible p ognos ic implica-
ions o his e en in his pa icula popula ion [23].
The esul s o ESE ha e p obably in luenced he ea men
o he pa ien s once a he end o ollow-up a g ea e pe -
cen age o pa ien s a e ea ed wi h β blocke s [24,25] in
g oup A han in g oup B (Table 1).
The p incipal limi a ions o his s udy a e: 1) no one
pa ien has done a es o p o oca ion o co ona y spasm
a ca h. labo a o y e en no pa ien included in he s udy
had segmen al wall abno mali ies wi h exe cise 2) The
p esence o absence o ischemia was only e alua ed by
ESE wi hou use o scin ig aphic s udies. 3) We excluded
all pa ien s wi h le en icula hype ophy and uncon-
oled a e ial hype ension ha cons i u es a g ea
numbe o pa ien in he eal wo ld o clinical p ac ice and
ha should be s udied in he u u e wi h he same p o o-
col.
Conclusion
We can conclude ha a ele an numbe o pa ien s wi h
ca diac X synd ome de elop signi ican in a en icula
g adien du ing exe cise and also ha mo phological a -
iables a e in ol ed in is pa hophysiology. The au ho s
belie e ha his phenomenon may cons i u e a new en i y
ha joins o he he e ogeneous g oup o pa ien s wi h
angina, ST-dep ession du ing eadmill exe cise es and
no mal co ona y a e iog aphy.
Table 6: Mul i a ia e analysis
Va iable -2 Log Likelihood Loss Func ion (p)
Age 114,1548 ,071918
Sex 109,0601 ,023868
LVOTi (mm/m2) 91,70272 ,000031
LVDVi ml/m281,35754 ,001299
RLVWT 78,80142 ,109878
LVMi g/m278,73733 ,800141
D1 dis ance 64,62039 ,000172
E o Angina 52,25502 ,000438
LVOTi; LVDVi; RLVWT; LVMi; D1 – as p e iously de ined
Table 4: De ails o wo-dimensional echoca diog am
G oup A G oup B p
LVOTi (mm/m2) 10,29 ± 0,9 11,4 ± 1 0,000
EF (%) 67,94 ± 5,4 66,90 ± 4,5 0,333
LVDVi ml/m244,8 ± 10 56 ± 11,6 0,000
D1 (mm) 10,72 ± 3,11 13,75 ± 2,98 0,000
LVOTi – le en icula ou low ac index; EF – ejec ion ac ion,
LVDVi – le en icula dias olic olume index; D1 – dis ance D1
measu ed as explained in igu e 1.
Table 2: Exe cise es da a
G oup A G oup B p
HR Baseline 70 ± 10,5 70 ± 11 0,769
HR Peak 163 ± 14 151 ± 17 0,001
Sys . BP Baseline 133 ± 13 135 ± 15 0,575
Sys . BP Peak 175 ± 21 173 ± 27 0,640
% heo e ical MHR 95 ± 7 91 ± 9 0,02
Du a ion seconds 659 ± 159 503 ± 175 0,000
Time eco e y HR 254 ± 99 260 ± 151 0,832
Double p oduc 28760 ± 4493 26232 ± 4760 0,015
Angina du ing ESE 22/33 (66%) 20/58(34%) 0,002
HR – hea a e; BP – blood p essu e; MHR – maxymal hea a e.
Table 3: De ails o echoca diog am M Mode
G oup A G oup B p
LVEDDi (mm/m2) 25,3 ± 2,8 28 ± 2,7 0,000
LVESDi 15,6 ± 2,4 17,4 ± 2,3 0,0002
FS (%) 38,9 ± 5,4 37,5 ± 4,9 0,219
IVSi (mm/m2) 5,2 ± 0,9 5,1 ± 0,8 0,62
PWi (mm/m2) 4,55 ± 0,7 4,59 ± 0,6 0,75
LVMi g/m273,9 ± 13,1 80,6 ± 13,9 0,028
LA (mm) 37,1 ± 3,2 37,8 ± 2,7 0,279
RLVWT 0,36 ± 0,068 0,33 ± 0,046 0,01
LVEDDi – le en icle eledias olic diame e index; LVESDi – le
en icle elesys olic diame e index; FS – accional sho ening; IVSi –
in e en icula sep um index; PWi – pos e io wall index; LVMi – le
en icula mass index; LA – le a ium; RLVWT – ela i e le
en icula wall hickness
Table 5: De ails o echoca diog am (Dopple )
G oup A G oup B p
CiLLD ml/m22086 ± 561 2235 ± 495 0,198
CWmáxLLD cms130 ± 15,8 120,6 ± 12,5 0,002
CWmáxO ho cms117 ± 14 111 ± 12 0,027
CWmáx 3 182 ± 15 158 ± 15 0,000
E cms85 ± 14 85 ± 16 0,963
A cms68 ± 19 67 ± 13 0,772
Dec. ime sec. 170 ± 34 175 ± 44 0,614
IVRT 85,9 ± 15 88,9 ± 11 0,286
PV 50 ± 12,8 47,9 ± 9,8 0,314
CiLLD – ca diac index in le la e al decubi us be o e de s a o he
exam; CWmáxLLD – máximal eloci y o low ob ained a apical i e
chambe iew wi h con inuous Dopple o ien ed h ough LVOT o
he ao a in le la e al decubi us; CwmáxO ho – máximal eloci y o
low ob ained a apical i e chambe iew wi h con inuous Dopple
o ien ed h ough LVOT o he ao a in o hos a ic posi ion;
CWmáx3-máximal eloci y o low ob ained a apical i e chambe
iew wi h con inuous Dopple o ien ed h ough LVOT o he ao a;
E- maximal eloci y o E wa e o mi al low; A – maximal eloci y o E
wa e o mi al low; Dec. Time sec.- decele a ion ime in seconds;
IRVT – iso olumic elaxa ion ime; PV p opaga ion o eloci y
e alua ed wi h M Mode colo .
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As as consequence o ou esul s, exe cise s ess echoca di-
og aphy should be pa o new diagnos ic algo i hm
whene e we suspec ha ou pa ien s wi h angina may
ha e ca diac X synd ome.
Addi ional ma e ial
Re e ences
1. Scandu a S, A cidiacono S, Felis S, Ba bagallo G, Des e W, D ago A,
Cal i V, Giu ida G: Dynamic obs uc ion o le en icula
ou low du ing dobu amine s ess echoca diog aphy: The
p obable mechanisms and clinical implica ions. Ca diologia
1998, 43:1201-8.
2. Pellikka PA, Oh JK, Bailey KR, Nichols BA, Monahan KH, Tajik AJ:
Dynamic in a en icula obs uc ion du ing dobu amine
s ess echoca diog aphy: a new obse a ion. Ci cula ion 1992,
86:1429-2.
3. Pe ei o J, Monse a L, Cas o-Bei as A: Labil subao ic obs uc-
ion, du ing exe cise s ess echoca diog aphy. Am J Ca diol
84(9):1119-23. 1999 No 1; A10-1.
4. Co im C, Osó io P, João I, Vic o AR, Co dei o P, Fazendas P, de
Oli ei a LM, Ca age a M: Do pa ien s wi h in a en icula g a-
dien s du ing dobu amine s ess echoca diog aphy ha e
in a en icula g adien s du ing exe cise es ing. Re Po
Ca diol 2002, 21(12):1461-5.
5. Co im C, João I, Vic o AR, Fazendas P, Co dei o P, Sequei a A,
Hen iksson I, de Oli ei a LM, Ca age a M: Exe cise induced en-
icula g adien in a young pa ien wi h posi i e eadmill
es and no mal co ona y a e ies. Re Po Ca diol 2002,
21:331-5.
6. Lau TK, Na a ijo J, S ainback RF: Pseudo-False-Posi i e exe cise
eadmill es ing. Tex Hea Ins J 2001, 28:308-1.
7. Co im C, Ca age a M: S ess-exe cise echoca diog aphy. Re
Po Ca diol 2000, 19(3):345-0.
8. Liko W, Segal BL, Kaspa ian H: Pa adox o no mal selec i e co -
ona y angiog ams in pa ien s conside ed o ha e unmis aka-
ble co ona y hea disease. N Engl J Med 1967, 276:1063-6.
9. Kemp HG, Ellio WC, Go lin R: The anginal synd ome wi h no -
mal co ona y a e iog aphy. T ans Assoc Am Physicians 1967,
80:59-70.
10. Kemp GH: Le en icula unc ion in pa ien s wi h he angi-
nal synd ome and no mal co ona y a e iog ams. Am J Ca diol
1973, 32:375-6.
11. Kaplan MN: Synd omes X: Two oo many. J Am Coll Ca diol 1992,
69:1643-4.
12. João I, Co im C, Fazendas P, Ma ins C, Osó io P, Hen iksson I,
Dua e JA, Pe ei a H, Oli ei a LM, Ca age a M: Changes in
egional con ac il y induced by e o in women wi h no -
mal co ona y angiog aphy – epo o a clinical case. Re Po
Ca diol 2001, 20(2):183-6.
13. Pupi a G, Mase i A, Kaski JC, Galassi AR, Ga ielides S, Da ies G,
C ea F: Myoca dial ischemia caused by dis al co ona y a e y
cons ic ion in s able angina pec o is. N Engl J Med 1990,
323:514-0.
14. Tweddel AC, Ma in W, Hu on I: Thallium scans in synd ome X.
B Hea J 1992, 68:48-0.
15. Eps ein SE, Cannon RO: Si e o inc eased esis ance o co o-
na y low in pa ien s wi h angina pec o is and no mal epica -
dial co ona y a e ies. J Am Coll Ca diol 1986, 8:459-1.
16. Picano E, La anzi F, Masini M, Alessand o D, L'abba e A: Use ulness
o high-dose dipy idamole-echoca diog aphy es o diagno-
sis o synd ome X. Am J Ca diol 1987, 60:508-2.
17. Bueno FC, Bailón IR, Salgue o RL, Doblas JJG, Cabeza AP, He nández
JP, F anco AD, Hidalgo LM, Gal án ET: Obs ucción dinámica
in a en icua izquie da inducida po es ue zo. Re Esp Ca -
diol 2004, 57(12):1179-87.
18. Bueno FC, Doblas JJ, Ga cia AM, Pinilla JMG, Na a o MJ, Gal án ET:
E o angina, no mal co ona y angiog am and dynamic le
en icula obs uc ion. J Am Soc Echoca diog 2007, 20:415-0.
19. Kaski JC: Ca diac synd ome X and mic o ascula angina. In
Ches pain wi h no mal co ona y angiog am: Pa hogenesis, Diagnosis and
Managemen Edi ed by: Kaski JC. London, UK: Kluwe Academic Pub-
lishe s; 1999:1-12.
20. Robe Le ine A, Gus Vlahakes J, Le eb e Xa ie , Luis Gue e o J,
Edwa d Cape G, Aji Yogana han P, A hu Weyman E: Weyman.
Papilla y muscle displacemen causes sys olic an e io
mo ion o he mi al al e. Expe imen al alida ion and
insigh s in o he mechanism o subao ic obs uc ion. Ci cula-
ion 1995:1189-5.
21. Quei oz e Melo J, Canada M, Ne es J, Fe ei a MM, de Sousa JS, Rebo-
cho MJ, de San os JC, Seab a-Gomes R: Anomalous inse ion o
mi al papilla y muscles in obs uc i e hype ophic myo-
ca diopa hy. Repo o 2 cases. Re Po Ca diol 1996,
15(6):499-3.
22. Co im C, Lou ei o MJ, Simões O, Co dei o P, Hen iksson I, Vinhas
H, Almeida A, Ca age a M: In a en icula g adien du ing
e o in a P o essional socce playe . Clinical signi icance.
Re Po Ca diol 2005, 24(11):1395-1.
23. Co im C, Almeida AG, Ca age a M: Clinical signi icance o
in a en icula g adien du ing e o in an adolescen
ka a e playe . Ca dio ascula Ul asound 2007, 5:39.
24. Bueno FC, Pinilla JMG, Doblas JJG, T ujillo AM, Baílon IR, Gal an ET:
Be a-blocke he apy o dynamic le en icula ou low
ac obs uc ion induced by exe cise. In e na ional Jou nal o
Ca diology 2007, 25:117(2):222-6.
25. Almeida S, Co im C, B andão L, Mi anda R, Lou ei o MJ, Simões O,
Lopes L, Ca age a M: Exe cise-Induced le en icula ou low
ac obs uc ion. A po en ial cause o symp oms in he eld-
e ly. Re Po Ca diol 2007, 26(3):257-2.
Addi ional ile 1
Echoca diog aphic images ob ained du ing exe cise. Apical ou and i e
chambe iew ob ained in apical window du ing exe cise con aining wo
dimensional and Dopple da a.
Click he e o ile
[h p://www.biomedcen al.com/con en /supplemen a y/1476-
7120-6-3-S1.wm ]
Addi ional ile 2
Images ob ained du ing exe cise es in he i s pa ien wi h IVG. Images
ob ained du ing he exam ha we epea ed, a e in o med consen was
ob ained, in he i s pa ien included in he s udy. IVG is easily obse ed
du ing exe cise echo.
Click he e o ile
[h p://www.biomedcen al.com/con en /supplemen a y/1476-
7120-6-3-S2.MPG]
Addi ional ile 3
Images ob ained du ing exe cise es in he i s pa ien wi h IVG and
SAM. Images ob ained du ing he exam ha we epea ed, a e in o med
consen was ob ained, in he i s pa ien included in he s udy. SAM o
mi al al e is easily obse ed du ing exe cise echo.
Click he e o ile
[h p://www.biomedcen al.com/con en /supplemen a y/1476-
7120-6-3-S3.MPG]
Addi ional ile 4
Images ob ained du ing exe cise es . Images ob ained du ing exe cise es
showing he posi ion o ope a o wi h he cubi al bo de o he igh hand
a a ched o he pa ien ches wall.
Click he e o ile
[h p://www.biomedcen al.com/con en /supplemen a y/1476-
7120-6-3-S4.wm ]