One hundred and two consecutive patients with a history of chest pain or recent previous myocardial infarction underwent maximal treadmill stress testing and coronary angiography. The diastolic blood pressure response to exercise was evaluated independently of ST segment change and systolic blood pressure. In the presence of a normal systolic blood pressure response an increase in diastolic blood pressure of 15 mm Hg on at least two determinations during the same stage of exercise was considered abnormal. In 99 patients an accurate diastolic reading was possible. Of these, 61 had a normal diastolic blood pressure response; in 25 of these the ST segment was ischaemic and seven had three vessel coronary artery disease. Thirty eight patients had an abnormal diastolic blood pressure response and 27 of these had an ischaemic ST response. Of the 11 with a negative ST response for ischaemia one had left main stem disease, seven three vessel disease, and three two vessel disease. Patients with an abnormal diastolic response had greater ST depression with more angina at a reduced workload than those with a normal diastolic response. In patients with chest pain an abnormal increase in diastolic blood pressure on exercise reflects severe coronary artery disease. Although no false positives occurred in this study there was an appreciable number of false negatives (sensitivity 46%) in both patients with chest pain and those with infarction. An abnormal diastolic response therefore represents a useful additional diagnostic indicator of coronary artery disease when the ST segment response is normal or borderline. When the diastolic pressure becomes increased with or without ST changes the likelihood of severe coronary artery disease is increased.
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