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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 33-38

The “Executive Cardiac Health Checkup”: A concoction of guidelines, practice, and perspective


Department of Cardiology, St. Gregorios Hospital, Parumala, Kerala, India

Date of Web Publication14-Feb-2022

Correspondence Address:
Dr. Sajan Ahmad Zulfikar
16FG, Skyline Edge, Thirumoolapuram, Thiruvalla, Kerala.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/khj.khj_6_21

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  Abstract 

PROLOGUE: The “Executive Master Cardiac Health Checkup” (wonder who made that up the first time!) patient makes his entrance into the cardiologist’s outpatient (OP) chamber. It doesn’t require the deductive skills of our friend in Baker street to identify that he has recently returned from either the USA or its neighbor across the Niagara. He looks healthy as a fresh cucumber. And smells even better (Calvin Klein probably). I offer him a smile, a seat, and my hand. He mistakes the intention of my third gesture and hurriedly thrusts a package on to my unsuspecting hand—the colourful and fancy looking Investigation File (gloss finish for the extra effect). “Doctor, all the test reports are here. Blood tests, ECG, Echo are all done. They wouldn’t let me do the TMT without seeing you,” he complained. I thank the technician silently in my mind for having followed my standing instruction faithfully (I have had my share of trouble with unsolicited treadmill tests). I tell him calmly that I wish to talk to him first about his health, then proceed with a clinical examination, and would then give my full attention to the reports in the file. He is clearly not happy. He gives a few not-so-furtive glances at his oversized watch to indicate that he didn’t have much time to waste.
POST SCRIPT: After the evaluation, I happily gave the gentleman a “clean chit” and congratulated him on the excellent condition of his heart. He didn’t look as happy as I wanted him to feel though. “Doctor, can I do the TMT now?,” he asked impatiently. One should know when a battle is lost. I smiled, and wrote “Routine check up, No risk factors” against the indication column on the TMT form. The patient proudly came back with the “Negative TMT.” This time, he was smiling from ear to ear, “Thank you Doc, I will be back next year around Christmas for the same check-up.” So much for evidence-based medicine!

Keywords: Executive Cardiac Health Checkup, guidelines, perspective


How to cite this article:
Zulfikar SA. The “Executive Cardiac Health Checkup”: A concoction of guidelines, practice, and perspective. KERALA HEART J 2021;10:33-8

How to cite this URL:
Zulfikar SA. The “Executive Cardiac Health Checkup”: A concoction of guidelines, practice, and perspective. KERALA HEART J [serial online] 2021 [cited 2022 Sep 25];10:33-8. Available from: http://www.csikhj.com/text.asp?2021/10/2/33/337623


  Introduction Top


Whether we like it or not, the “Executive Cardiac Checkup” is here to stay (especially in a state such as Kerala, with its high health awareness levels and health-seeking behavior). The discussion in this article is limited to the realm of cardiac evaluation in the apparently healthy subject who comes for a consultation in the primary prevention perspective. Let us initially go through what the international guidelines advocate in this setting. The key elements of the guidelines that are relevant to our discussion are summarized next. After this, we will go on to try and develop a strategy that can be applied in a practical and meaningful way during our routine clinical practice.


  2019 ACC/AHA GUIDELINE ON THE PRIMARY PREVENTIONOF CARDIOVASCULAR DISEASE Top


  • Should cardiovascular risk be assessed routinely in adults? The 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease asserts that atherosclerotic cardiovascular disease (ASCVD) risk estimation is the foundation of primary prevention. Therefore, the assessment of traditional CVD risk factors and calculation of 10-year ASCVD risk score by the Pooled Cohort Equation (PCE) is recommended for all adults aged 40–75 years (Class I). This would require the following information: age, sex, race, systolic blood pressure (BP), diastolic BP, total cholesterol, HDL cholesterol, history of diabetes, smoking status, and hypertension treatment.


  • For younger adults (20–39 years), the assessment of traditional cardiovascular disease (CVD) risk factors should be done at every 4–6 years’ interval (Class IIa).


  • Calculation of body mass index (BMI) is recommended annually to identify individuals with overweight/obesity for weight loss considerations (Class I). Measurement of waist circumference is also reasonable (Class IIa).


  • Low-dose aspirin (75–100 mg orally daily) should not be administered for the primary prevention of ASCVD among adults of any age who are at increased risk of bleeding (Class III). Low-dose aspirin (75–100 mg orally daily) should not be administered on a routine basis for the primary prevention of ASCVD among adults >70 years of age (Class III). Low-dose aspirin (75–100 mg orally daily) might be considered for the primary prevention of ASCVD among select adults 40–70 years of age who are at higher ASCVD risk but not at increased bleeding risk (Class IIb).
  • [1]


      2017 ACC/AHA HTN GUIDELINE Top


  • BP should be measured and characterized as normal, elevated, or stage 1 or 2 hypertension to prevent and treat high BP (Class I).


  • Out-of-office BP measurements are recommended to confirm the diagnosis of hypertension and to titrate BP-lowering medications in conjunction with clinical interventions (Class I).


  • In adults with an untreated SBP greater than 130 mmHg but less than 160 mmHg or DBP greater than 80 mmHg but less than 100 mmHg, it is reasonable to screen for the presence of white coat hypertension by using either daytime ABPM or HBPM before the diagnosis of hypertension (Class IIa).


  • Screening for specific forms of secondary hypertension is recommended in the presence of clinical indications/suggestive physical examination findings or in resistant hypertension (Class I).


  • In adults with hypertension, screening for primary aldosteronism is recommended in the presence of any of the following concurrent conditions: resistant hypertension, hypokalemia (spontaneous or substantial, if diuretic induced), incidentally discovered adrenal mass, family history of early onset hypertension, or stroke at a young age <40 years (Class I).
  • [2]


      2018 ACC/AHA CHOLESTEROL GUIDELINE Top


  • A fasting or nonfasting plasma lipid profile is recommended in all adults aged 20 years and older (Class I).


  • In children or adolescents with a family history of early CVD or significant hypercholesterolemia, it is reasonable to measure lipid profile as early as 2 years of age to detect familial hypercholesterolemia (FH) or rare forms of hypercholesterolemia (Class IIa).


  • In children and adolescents without cardiovascular risk factors or a family history of early CVD, it may be reasonable to measure a fasting lipid profile or nonfasting non-HDL-C once between the ages of 9 and 11 years, and again between the ages of 17 and 21 years, to detect moderate-to-severe lipid abnormalities (Class IIb).


  • Risk assessment in women should include specific factors such as premature menopause (age <40 years) and a history of pregnancy-associated disorders: hypertension, preeclampsia, gestational diabetes mellitus, small-for-gestational-age infants, and preterm deliveries (Class I).


  • In intermediate-risk adults, risk-enhancing factors favor the initiation or intensification of statin therapy (Class IIa). These include: family history of premature ASCVD (<55 years in males and <65 years in females), primary hypercholesterolemia, metabolic syndrome, CKD, chronic inflammatory conditions, premature menopause (<40 years), history of preeclampsia, high-risk race/ethnicity (e.g., South Asian), and lipid/biomarkers: persistently elevated, primary hypertriglyceridemia (≥175 mg/dL), and if measured: elevated hs-CRP ≥2mg/L, elevated LP(a) ≥50 mg/dL, or >125 nmol/L (a relative indication is family history of premature ASCVD), elevated ApoB ≥130 mg/dL and ABI <0.9.


  • Diabetic-specific risk enhancers that would make it reasonable to start statin in adults 20–39 years of age with diabetes mellitus include: long duration of diabetes (>10 years of type 2 diabetes mellitus, >20 years of type 1 diabetes mellitus), albuminuria (>30 mcg of albumin/mg creatinine), estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2, retinopathy, neuropathy, or ankle-brachial index (ABI; <0.9); (Class IIb).


  • In intermediate-risk or selected borderline-risk adults, if the decision about statin use remains uncertain, it is reasonable to use a coronary artery calcium (CAC) score in the decision to withhold, postpone, or initiate statin therapy (Class IIa).


  • If the CAC score is zero, it is reasonable to withhold statin therapy and reassess it in 5–10 years, as long as higher risk conditions are absent (diabetes mellitus, family history of premature CHD, cigarette smoking). If CAC score is 1–99, it is reasonable to initiate statin therapy for patients >55 years of age. If CAC score is 100 or higher or in the 75th percentile or higher, it is reasonable to initiate statin therapy (Class IIa).
  • [3]


      2018 ADA GUIDELINE Top


  • Screening for type 2 diabetes mellitus should be considered in asymptomatic adults. Generally, for all people, testing for diabetes mellitus should begin at the age of 45 years. Repeat testing is reasonable at a minimum interval of 3 years, if the initial tests are normal. However, overweight/obese individuals or those with risk factors for diabetes must undergo testing regardless of age.
  • [4]


      2010 ACC/AHA GUIDELINE FOR EVALUATION OF ASYMPTOMATIC ADULTS Top


  • Family history of ASCVD should be obtained in all asymptomatic adults (Class I).


  • Beyond a standard lipid profile, measurement of lipoproteins, apolipoproteins, particle size, and density is not recommended (Class III).


  • C reactive protein (CRP) estimation has no role in asymptomatic high-risk adults and in asymptomatic low-risk adults (men <50 years, women <60 years), Class III.


  • Urine analysis to detect microalbuminuria is reasonable in asymptomatic patients with diabetes and/or hypertension (Class IIa).


  • A resting electrocardiogram (ECG) is reasonable for the assessment of cardiovascular risk in asymptomatic adults with diabetes or hypertension (Class IIa). In the absence of diabetes or hypertension, the recommendation is weaker (Class IIb).


  • Echocardiography to detect left ventricular hypertrophy (LVH) may be considered in asymptomatic adults with hypertension (Class IIb). Apart from this, echocardiography is not recommended for the routine assessment of coronary artery disease in asymptomatic adults (Class III).


  • Exercise ECG (treadmill test [TMT]) is not routinely useful in the evaluation of asymptomatic adults. However, it may be useful for cardiovascular risk assessment in intermediate-risk, asymptomatic adults (including sedentary adults considering starting a vigorous exercise program), particularly when attention is paid to non-ECG markers such as exercise capacity (Class IIb).


  • Measurement of ABI is reasonable in asymptomatic adults at intermediate risk (Class IIa).


  • Stress echocardiography is of no benefit and is not useful in the assessment of cardiovascular risk in asymptomatic adults at low or intermediate risk (Class III).
  • [5]


      2002 ACC/AHA GUIDELINE UPDATE FOR EXERCISE TESTING Top


  • There is no Class I recommendation for exercise testing in asymptomatic people without known coronary artery disease. In fact, the screening of asymptomatic men and women for coronary artery disease (CAD) with the help of TMT is not recommended (Class III).


  • Class IIa recommendation is the evaluation of asymptomatic diabetic people who plan to start vigorous exercise. (This recommendation was not there earlier in the ACC/AHA 1997 Guideline for exercise testing and was newly added in the 2002 update.)


  • The Class IIb recommendations are:



    • 1. Evaluation of people with multiple risk factors (defined as hypercholesterolemia, hypertension, smoking, diabetes, and family history of heart attack or sudden cardiac death in a first-degree relative younger than 60 years), and


    • 2. Evaluation of asymptomatic men older than 40 years and women older than 50 years:



      • a. Who plan to start vigorous exercise (especially if sedentary) or


      • b. Who are involved in occupations in which impairment might impact public safety or


      • c. Who are at high risk for CAD due to other diseases (e.g., chronic renal failure)
  • [6],[7]


      A MIDDLE PATH? Top


    History and clinical evaluation

    Assessment of traditional CVD risk factor status must be done in all subjects who present for an “Executive Cardiac Checkup.” This would include information regarding age, gender, hypertension, diabetes, dyslipidemia, obesity, smoking status, exercise, diet, and psychosocial stress. Family history of (premature) CVD needs to be elicited. The interaction can be a good platform to emphasize on smoking cessation. The subject’s symptom status has to be accurately assessed. It should be understood why he/she has chosen to come for an evaluation—as a general measure or in view of some recent symptom or concern. Activities of daily living must be assessed. The functional status of the subject must be understood. Symptoms suggestive of coronary artery disease or any form of heart disease, for that matter, must be elicited. General examination and cardiovascular examination should be followed by a focused evaluation of other “systems.” The presence of comorbidities such as anemia, lung disease, renal disease, hypothyroidism, and psychiatric illness must be assessed. Peripheral pulses must be examined in all, especially so in patients at risk of peripheral arterial disease (e.g., smokers, diabetes mellitus). BP of both upper and lower limbs should be measured, especially in young hypertensives.

    Blood pressure (BP)

    The measurement of BP is simple, ubiquitous, safe, convenient, and inexpensive. And it does not require a blood sample to diagnose hypertension. Systemic hypertension is a very common condition. The benefits of early detection and management of high BP are noncontroversial. Hence, it is preferable that all adults have a measurement of BP annually or at every instance of encounter with a medical professional.

    Diabetes mellitus

    Diabetes mellitus has a high prevalence in India, particularly in Kerala. Early diagnosis is, indeed, important. Hence, all adults ideally need to have an FBS value every year, especially in susceptible individuals (impaired fasting glucose levels in the past, family history of diabetes, obesity, and metabolic syndrome).

    Dyslipidemia

    Dyslipidemia is a very important risk factor for CVD. Measurement has been simplified by doing away with the “fasting” requirement. If affordability is not an issue, an annual assay of the lipid profile is preferable, especially in those with a positive family history.

    Investigations

    Blood investigation would typically include lipid profile, FBS/HBA1c, Hb, renal and hepatic function, and serum electrolytes (sodium and potassium). Urine microalbuminuria is desired. TSH is required if clinically indicated.

    CAD evaluation

    Routine screening for CAD in an asymptomatic adult is not indicated. The optimal control of CVD risk factors is far more important and useful. However, one or more of the following tests are usually done as part of the “package.”

    ECG

    An ECG must definitely be part of the evaluation as it has been, and continues to be, the quintessential “cardiac test.” Routine ECG for all adults is not required, but is absolutely required in any one who happens to come for an “executive cardiac” checkup. It is inexpensive and easily available. However, the sensitivity to detect CVD is limited as serious underlying CAD can coexist along with an absolutely normal ECG. A normal ECG gives a sense of confidence to the patient. Normal variants in ECG should be recognized as such.

    Echocardiography

    Even though routine echocardiography is not recommended as per guidelines, the current scenario of “executive health check ups” dictates that a standard echocardiography study is also done as part of the package. It is very unlikely that someone who comes for such a checkup will go peacefully if an “echo” is not done. In our part of the world, with its easy availability, essentially nonexistent waiting period, and reasonable cost, getting an echo has become easier than a dental appointment. And in today’s scenario, no cardiologist can afford to miss a diagnosis by denying an echo to a patient who comes asking for it (medical practice, too, has become democratic over the years). A normal echo report boosts the confidence of the subject. On the other hand, detection of abnormalities such as valvular heart disease, cardiomyopathies could impact further patient counseling, lifestyle modification, and management. Findings of LVH or LA dilatation in a patient with hypertension could motivate the patient to be more serious about his BP control and be more compliant with his medications. At the same time, nonsignificant findings such as the “mild” MVP pandemic, trivial MR or TR should not become a reason for anxiety for the patient and must be treated with the disdain that these innocuous “lesions” deserve.

    Chest X-ray

    A chest X-ray need not always be taken, especially as it involves a small amount of radiation. In patients who complain of dyspnea on exertion, an X-ray would be a useful tool to rule out major lung disorders, considering the limitations of the respiratory system examination, especially in obese patients.

    Treadmill test (TMT)

    The tricky part of the equation is the consideration of a TMT or an exercise ECG stress test. As a general policy, it would be prudent to avoid a TMT unless the patient has a symptom that requires CAD to be ruled out. The perils of an unnecessary TMT include a false positive or a borderline result that results in potentially costly and complicated testing, such as a coronary angiography or a CT coronary angiography or a perfusion imaging. Another danger of a false-positive test would be unnecessary long-term pharmacotherapy with its attendant side effects (e.g., aspirin and bleeding risk). Knee osteoarthritis is one reason why many subjects themselves desist a TMT, being satisfied with a normal ECG and a normal echocardiogram, thus making life simpler for themselves and for the cardiologist. However, there are situations where patients desire or demand a “guarantee” rather than a reassurance that they do not have significant obstructive CAD. In such circumstances, a negative TMT report would be most welcome, both for the patient as well as for the cardiologist. However before proceeding with this exercise, potential results and the further evaluation route must be discussed with the patient. In all subjects undergoing a TMT, it is essential to rule out anemia as it is a common cause of a false-positive TMT, especially among females. Baseline ECG abnormalities, presence of systemic hypertension, and LVH are some of the other factors that sometimes lead to a false positive or a borderline treadmill result, despite the absence of CAD on subsequent invasive testing.

    In a totally asymptomatic and apparently healthy diabetic adult who is able to carry on with his routine activities comfortably, there is no need to order a TMT. However, the presence of “dyspnea on exertion” might complicate the decision algorithm. This phenomenon is very common among people older than the age of 50 years, especially among physically inactive and deconditioned subjects. Especially in diabetic patients, this would raise the specter of an “anginal equivalent,” and this might prompt a TMT. Whether the detection and subsequent revascularization of subclinical CAD in a diabetic patient would alter the outcome in terms of mortality and/or morbidity reduction is yet to be clear. The very low “event rate” in the so-called “stable CAD” subset also needs to be understood. It is, of course, only natural that somebody who has a positive TMT in the current era would invariably be asked to undergo further diagnostic testing, most commonly a conventional coronary angiography. Although all of us might have had anecdotal experiences with apparently healthy people turning out to have left main or left anterior descending CAD after undergoing angiography following a positive TMT, this can hardly be reason enough to recommend routine TMT in the general population, or for that matter, even in the high-risk groups such as those with diabetes. The guidelines had mentioned chronic kidney disease too as such a high-risk group. However, what would be the safety of such a strategy? If all patients with chronic kidney disease (e.g., diabetic nephropathy, hypertensive renal disease) start undergoing TMTs, all the “positive” patients would be advised coronary angiography with the attendant risk (albeit mild and/or exaggerated) of contrast-induced worsening of renal function.

    A difficult situation arises when a subject comes for evaluation in view of a recent ACS or revascularization in a sibling. In the setting of a strong family history of CAD, especially in the presence of shared risk factors such as diabetes or dyslipidemia, the apprehension of the subject is understandable. This is one situation where a TMT would be advised more liberally. Another common scenario is that of a diabetic patient who is already on aspirin (started by the physician/cardiologist earlier) for the purpose of “primary prevention.” As the available evidence is against the routine use of aspirin, aspirin might be stopped more confidently if the TMT is negative after discussion with the patient. There is also the case of patients who come for a cardiac evaluation prior to undertaking long journeys or pilgrimages. In this setting, especially in patients who belong to the “high risk” category or who have equivocal symptoms, a negative TMT with a good exercise tolerance would be reassuring. On the other hand, if the TMT is positive, say for example in a diabetic patient, he (or she, for that matter!) would definitely be cautioned against undertaking strenuous activity and would be evaluated further as per standard protocol.

    The recent ISCHEMIA trial results have revived the concept that in stable ischemic heart disease (SIHD), revascularization (intervention/CABG) may not really alter the CV outcome. So, even if we do a TMT, even if it turns out positive, even if the angiography reveals CAD, and even if we revascularize, if there is no change in the outcome, should we go through this “exercise” at all? Most diabetic patients older than the age of 40 years would be on a statin as per the current recommendations and ASCVD risk calculation, especially if the risk-enhancing factors are also considered. If CAD is detected, what change in pharmacotherapy would happen? An antiplatelet agent would be added, most commonly aspirin at a dose of 75 mg once daily. Statin therapy would be intensified and a beta blocker might also be added.

    What about the “lead time bias”? Take a hypothetical patient who starts doing annual TMTs from the age of 50. At the age of 57 years, his TMT becomes “mildly positive” and he undergoes a coronary angiography, which reveals a single vessel disease (70% stenosis of a 2.5 mm caliber obtuse marginal). He undergoes a PCI with a drug eluting stent and is happy that his treadmill routine has helped to detect his CAD “before it caused a heart attack.” On the other hand, if he had not undergone routine TMTs, he may have remained asymptomatic till the age of 64 years! The counterargument would be that early detection of disease theoretically would lead to better “treatment” of CAD and its risk factors, with better and lower LDL levels, better BP control, and better diet and exercise habits, consequently leading to a better “natural history.” It would be difficult to have a randomized controlled trial to prove or disprove this.


      A CONCLUSION (OF SORTS) Top


    In the Google era, patients will increasingly continue to visit cardiologists for executive cardiac checkups. In addition, as the prevalence of cardiologists increases, so too will various forms of cardiac evaluations. The fundamental principle of the doctor–patient interaction in this setting of preventive cardiology services should be the promotion of health rather than the fear of disease. A distinction must be there in the extent of evaluation of the truly asymptomatic vs. symptomatic patient, ensuring that there is no unnecessary aggression in the former and no dilution in the evaluation of the latter either. A unified approach incorporating clinical assessment, investigations, and scoring systems is essential. The strategy should be individualized, keeping in mind the age, lifestyle, aspirations, as well as the educational, social, and economic background of the patient (of course, in these difficult times, a medicolegal angle may also be there in some far corner of our mind). Decision-making must always be made on the foundations of common sense and communication. With evidence and guidelines changing every now and then, it is imperative that we keep ourselves (and our electronic devices) updated to streamline our thought process and optimize patient outcome.

    Acknowledgment

    Special thanks are due to Dr. George Koshy A, Cosmopolitan Hospital, Thiruvananthapuram, Dr. Cherian Koshy, Holy Cross Hospital, Adoor, Dr. Abhilash TG, Travancore Medicity, Kollam, and Dr. James Thomas, Bharat Hospital, Kottayam for their valuable inputs.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
      References Top

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    Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. Circulation 2019;140:e596-646.  Back to cited text no. 1
        
    2.
    Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. Hypertension 2018;71:e13-115.  Back to cited text no. 2
        
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    Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. Circulation 2019;139:e1082-143.  Back to cited text no. 3
        
    4.
    Riddle MC, Bakris G, Blonde L, Boulton AJM, D’ Alessio D, Groot M, et alAmerican Diabetes Association Standards of Medical Care in Diabetes 2018. Diabetes Care 2018;41(Suppl 1):s13-27.   Back to cited text no. 4
        
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    Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA, et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2010;122:e584-636.  Back to cited text no. 5
        
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    Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, et al. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee to update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol 2002;40:1531-40.  Back to cited text no. 6
        
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    Gibbons RJ, Balady GJ, Beasley JW, Bricker JT, Duvernoy WF, Froelicher VF, et al. ACC/AHA guidelines for exercise testing: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Exercise Testing). J Am Coll Cardiol 1997;30:260-315.  Back to cited text no. 7
        




     

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      In this article
    Abstract
    Introduction
    A MIDDLE PATH?
    A CONCLUSION (OF...
    2019 ACC/AHA GUI...
    2017 ACC/AHA HTN...
    2018 ACC/AHA CHO...
    2018 ADA GUIDELINE
    2010 ACC/AHA GUI...
    2002 ACC/AHA GUI...
    References

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