[Detection of myocardial ischemia in chronic Chagas disease patients with atypic precordial pain by exercise and Holter tests]

Abstract

Purpose: To determine the incidence and characteristics of myocardial ischemia, as detected by stress electrocardiography and Holter monitoring in Chagas' patients whose main complaint was precordial pain.

Methods: Thirty-one consecutive patients with Chagas' disease diagnosed on the basis of clinical and serological tests, and precordial pain severe enough to warrant cardiac catheterization were studied. Mean age was 54.4 +/- 9.6 years, and 51% were males. EKG changes indicative of myocardial ischemia were sought during maximal exercise and also during 24-hour Holter monitoring. The detection of myocardial ischemia by each one of these tests was compared by Fischer exact test, and also correlated to anatomical and functional results of coronary angiography at rest and after standardized hyperventilation for detecting coronary vasospasm.

Results: Baseline EKG changes mainly associated with ventricular conduction defects precluded the analysis of the ST segment in 11 patients. Among the other 20 patients, 7(35%) had angina during the exercise test, of whom only 2(10%) showed concomitant ischemic ST changes: one had 90% stenosis in the circumflex branch and the other 50% reduction of luminal diameter in a intramyocardial segment of the left anterior descending coronary artery, undergoing further 30% constriction after hyperventilation, with pain and ST-elevation that responded to nitrate administration. Thus, a positive correlation between a positive EKG exercise test with accompanying symptoms, and organic/functional coronary artery disease was found (p = 0.03). Holter tracings of good quality were obtained in 16 patients. Angina-like symptoms occurred in 25% of these patients, without concomitant ischemic or dysrhythmic EKG changes. Conversely, silent ischemia was detected in 1 (5%) patient during exercise and in 3 (18%) patients during the Holter monitoring. None of these patients had any evidence of organic or functional alterations in the coronary arteries. The absence of significant (> 50%) narrowing of the coronary arteries, at baseline and after hyperventilation, was also documented in the 11 patients in whom no valid EKG tracings were obtained for analysis.

Conclusion: EKG-based methods for detecting myocardial ischemia are of limited value in the general population with Chagas' disease presenting with precordial pain, due to the high prevalence of baseline ST changes. The overall incidence of significant coronary artery disease, as detected by angiography, was low but not negligible in this population of Chagas' patients with precordial pain (4%). Nevertheless, a positive EKG test based on ST changes and accompanying pain has a 100% positive predictive accuracy for the presence of organic or functional coronary abnormalities. No additional yield was obtained with Holter monitoring, for the elucidation of the pathophysiology of the precordial pain in Chagas' patients with atypical angina. The significance of episodes of silent ischemia in some of these patients, with angiographically normal coronary arteries, remains to be determined.