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Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

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On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Professor and Head
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Saraswati Dental College
On Sep 2018

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On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : September | Volume : 17 | Issue : 9 | Page : OC01 - OC04 Full Version

Significance of Rate-Pressure Product and Duke Treadmill Score in Predicting Disease Severity in Patients with Coronary Artery Disease: A Cross-sectional Study

Published: September 1, 2023 | DOI:
EV Shaveen, K Jayaprakash, V Sudhakumary, Suresh Madhavan, Cicy Bastian, VL Jayaprakash

1. Consultant Cardiologist, Department of Cardiology, Sree Narayana Institute of Medical Science, Chalakka, Kuthiathode, Kerala, India. 2. Additional Professor, Department of Cardiology, Government Medical College, Ernakulam, Kerala, India. 3. Associate Professor, Department of Cardiology, Government Medical College, Kottayam, Kerala, India. 4. Additional Professor, Department of Cardiology, Government Medical College, Kottayam, Kerala, India. 5. Professor, Department of Cardiology, Government Medical College, Ernakulam, Kerala, India. 6. Professor, Department of Cardiology, Government Medical College, Kottayam, Kerala, India.

Correspondence Address :
Dr. K Jayaprakash,
“Sreelekshmi”, Arattukadavu Road, Gandhinagar, P.O. Kottayam-686008, Kerala, India.


Introduction: Exercise electrocardiography is a well-established and cost-effective investigation for evaluating Coronary Artery Disease (CAD). The Rate-pressure Product (RPP), which is the product of maximal Systolic Blood Pressure (SBP) and peak Heart Rate (HR) during exercise, is a widely accepted parameter reflecting cardiac work and evaluating ventricular function. The use of Duke Treadmill Score (DTS) improves the diagnostic accuracy of exercise-induced ST-segment depression and has been observed to provide independent prognostic information. It has been shown that DTS provides information about the complexity of coronary artery lesions assessed by invasive coronary artery testing.

Aim: To determine the significance of RPP and DTS in predicting the severity and complexity of angiographic lesions in patients with Stable Ischemic Heart Disease (SIHD) and a positive Treadmill Test (TMT).

Materials and Methods: This study involved 100 consecutive patients with a positive TMT but no prior history of Acute Coronary Syndrome (ACS) who underwent coronary angiography at Government Medical College, Kottayam, Kerala, India, between March 2018 and March 2019 after obtaining ethical clearance from the Institutional Review Board. The DTS and RPP were calculated for these patients. All patients then underwent coronary angiography, and their SYNTAX scores were calculated. Correlation analysis was performed to assess the relationship between DTS, RPP, and SYNTAX score using Spearman's correlation coefficient. The Kruskall-Wallis test was used to compare risk factors among groups.

Results: A total of 100 patients were evaluated, ranging in age from 40 to 74 years with an average age of 57 years. The average SYNTAX score was 15, ranging from 2 to 56. The average Duke TMT score was -5.2, ranging from 6 to -22. There was a significant negative correlation between DTS and angiographic severity determined by SYNTAX score (r=-0.702, p=0.001). The average RPP was 22174, ranging from 14000 to 37620. The study showed a significant negative correlation between RPP and SYNTAX score (r=-0.201, p=0.04). Diabetic patients had a significantly higher SYNTAX score compared to non-diabetics (r=-0.602, p=0.013). Additionally, a significant negative correlation was observed between the Metabolic Equivalents (METs) attained, duration of exercise, and the SYNTAX score.

Conclusion: DTS and RPP derived from the exercise treadmill test have a significant negative correlation with the severity and complexity of CAD as determined by the SYNTAX score in coronary angiography.


Stable ischaemic heart disease, SYNTAX score, Tread mill test

Exercise testing is widely used for the diagnosis of CAD and to assess disease severity and prognosis. The increasing use of cardiac imaging procedures has resulted in a marked increase in healthcare expenditures for CAD assessment (1),(2). Exercise Electrocardiogram (ECG) remains the least expensive investigation for diagnosing patients with suspected CAD (1). Using the standard diagnostic criteria, the exercise ECG test has a sensitivity of 68% and specificity of 77% (3). However, its sensitivity and specificity are limited compared to other exercise-based diagnostic tests such as Stress Echocardiography or exercise thallium-201 myocardial perfusion imaging. To improve the sensitivity and specificity of the exercise ECG test, various scoring systems have been introduced. The Duke Treadmill Score (DTS) (4),(5) is a widely validated index used to enhance the diagnostic accuracy of the exercise ECG test. It has been observed that assessing DTS provides additional information about the complexity of CAD before invasive investigations such as coronary angiography. Similarly, the Rate-pressure Product (RPP) has been recognised as another parameter for predicting disease severity (6). RPP is calculated by multiplying SBP and peak HR and correlates well with myocardial oxygen consumption. Previous studies have shown that a higher RPP is associated with less significant CAD (7),(8), good ventricular function, and a non-ischemic status (9).

The SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) score was developed as part of the SYNTAX trial to objectively quantify the severity and extent of CAD (10). Each significant lesion (defined as a diameter stenosis of >50% in vessels with a minimum diameter of 1.5 mm) is visually assessed in the angiogram and analysed according to the American College of Cardiology/American Heart Association lesion classification system. Each coronary artery segment is given a score based on lesion morphology and complexity. The scores of individual lesions are summed to derive the final score. The derived score was categorised into three groups as evaluated in the SYNTAX trial (low: 0 to 22, intermediate: 23 to 32, high: >32) (10),(11).

The aim of the present study was to determine the significance of RPP and DTS in predicting the severity and complexity of coronary artery stenosis in patients with SIHD and a positive TMT and to define cut-off points for identifying complex coronary anatomy through non-invasive evaluation. If there is a significant correlation between DTS and RPP with the SYNTAX score in the present study, it may be possible to predict the severity of angiographic lesions in patients with stable CAD noninvasively based on these parameters.

Material and Methods

This was a cross-sectional study conducted from March 2018 to March 2019 in the Department of Cardiology, Government Medical College, Kottayam, Kerala, India. Ethical clearance was obtained from the Institutional Review Board with approval number 64/2018 dated 30-10-2018.

Sample size estimation: was done using the formula: Sample size for proportions= (Z²*P*Q)/d². Using the values at a 95% confidence level, a sample size of 94 was obtained, which was rounded off to one hundred (100).

Inclusion criteria: Patients with exertional angina or exertional dyspnoea with a positive TMT undergoing coronary angiography from March 2018 in the Cardiology Department of a tertiary-level academic healthcare institution were included in the study.

Exclusion criteria: Patients with previous ST elevation Myocardial Infarction, Non-ST Elevation Acute Coronary Syndrome (NSTE ACS), coronary artery bypass graft, previous Percutaneous Transluminal Coronary Angioplasty (PTCA), or valvular heart disease were excluded from the study.


After obtaining informed consent, patients were evaluated clinically. Baseline investigations including 2D echo were performed. These patients were then subjected to a Treadmill test using the Bruce protocol (5). The functional capacity of the patients in terms of Metabolic Equivalents (METs) attained during the exercise stress test was recorded (12). DTS and RPP were calculated in those patients with a positive TMT. DTS was calculated using the following equation: DTS = exercise time - (5 × ST deviation) - (4 × exercise angina index). The exercise angina index was expressed in terms of the severity of angina during the test:

• 0 - no angina;
• 1 - non-limiting angina;
• 2 - exercise-limiting angina.

The DTS was grouped into low-risk (with a score of ≥ +5), moderate-risk (with scores ranging from -10 to +4), and high-risk (with a score of ≤ -11) categories (5). The RPP was calculated by multiplying the maximum HR with the maximum SBP (13).

Patients with a positive TMT then underwent coronary angiographic study. Coronary angiography was performed through a radial approach. Femoral access was chosen when the radial approach was not feasible due to technical reasons. A coronary lesion was considered significant when the stenosis of the left main coronary artery was ≥50%. For the other coronary arteries, stenosis ≥70% was considered significant.

The overall SYNTAX score was calculated by scoring each coronary lesion independently based on pre-determined lesion features in arteries with a caliber of 1.5 mm and 50% diameter stenosis. Patients were divided based on SYNTAX scores:

• Low (≤22),
• Intermediate (≥ 23 to 32),
• High (≥ 33) (10).

The DTS, RPP, and SYNTAX score were evaluated and correlated among all the patients.

Statistical Analysis

Statistical analysis was performed using IBM Statistical Package for Social Sciences(SPSS) version 18.0. Continuous and normally distributed variables were presented as mean ± Standard Deviation (SD). Spearman's correlation analysis was used to assess the correlation between DTS and the SYNTAX score, RPP and the SYNTAX score. A p-value ≤0.05 was considered statistically significant.


One hundred patients were evaluated. The age of these patients ranged from 40 to 74 with an average age of 57 years. Most of the patients presented with effort angina as the predominant symptom. Another common presenting symptom was dyspnoea on exertion. Sixty-one patients (61%) were males, and 39 (39%) were females. The most common risk factor associated was hypertension. A total of 57 patients were hypertensive, and 53 were diabetic. Dyslipidemia was found in 10 patients. Thirty-nine patients were smokers, and 31 patients consumed alcohol.

One patient had CKD, and three patients were diagnosed with hypothyroidism. Two patients had a history of CVA. Three patients had baseline regional wall motion abnormality, and one patient had left ventricular dysfunction. The average SYNTAX score was 15 and ranged from 2 to 56. The average Duke TMT score of the patients was -5.2 and ranged from 6 to -22. Most patients below 60 years had a low SYNTAX score (n=53, 82%). In the age group between 61-70 years, proportionately more patients belonged to the intermediate or high SYNTAX score (n=8, 25.8%), and in patients aged more than 70 years, 40% (n=2) had a high SYNTAX score; however, the difference was not statistically significant (p=0.459) (Table/Fig 1).

In diabetic patients, the SYNTAX score was significantly higher compared to non-diabetics (r=-0.602, p=0.013) (Table/Fig 2). There was no significant influence of sex category on the SYNTAX score in the study population (p=0.837). No significant difference was observed in the anatomical complexity of the stenosis assessed by the SYNTAX score between patients with and without hypertension (p=0.137). Smoking and alcoholism did not significantly influence the SYNTAX score (p=0.128 and 0.176).

There was a significant negative correlation between DTS and angiographic severity assessed by the SYNTAX score (r=-0.702, p=0.001). The high-risk DTS group and the medium-risk group had a higher SYNTAX score, 44.4% and 55.6%, respectively, whereas none of the low-risk DTS group had a high SYNTAX score [Table/Fig-3,4]. It was observed that patients with a DTS score of one or more had a lower chance of having a SYNTAX score of more than 22 (p=0.03). There was a significant negative correlation between RPP and the SYNTAX score (R=-0.201, p=0.04) [Table/Fig-5,6]. Additionally, the Spearman correlation showed a significant negative correlation between exercise duration and the SYNTAX score (R=-0.387, p=0.02) (Table/Fig 7), as well as between METs achieved and the SYNTAX score (R=-0.287, p=0.01).

In the study population, 33% had single vessel disease, 29% had three vessel disease, 23% had double vessel disease, and 15% had left main CAD, either alone or with disease in other vessels (Table/Fig 8). The median RPP was highest among patients with single vessel disease and lowest in patients with left main coronary artery stenosis with three vessel disease. DTS was lowest in patients with left main coronary artery stenosis associated with either double or triple vessel disease. DTS was highest in patients with single vessel disease (Table/Fig 9).


The present study analysed the significance of RPP and DTS in predicting significant angiographic lesions in patients with stable CAD and a positive TMT. There was a significant negative correlation between DTS and angiographic severity assessed by the SYNTAX score (r=-0.702, p=0.001). The high-risk DTS group and the medium-risk group had a higher SYNTAX score compared to the low-risk group, 44.4% and 55.6%, respectively. This is in line with the study by Dzenkeviciute V et al., which showed a significant negative correlation between DTS and significant coronary artery stenosis using the SYNTAX score (r=-0.181, p=0.005) (4). Shaw LJ et al., observed that 83% of high-risk DTS patients had 2-vessel or 3-vessel or left main coronary disease (14). Low-risk patients had no significant coronary stenosis (60%) or had single vessel coronary disease (16%).

The present study was able to find a negative correlation between RPP and the SYNTAX score (r=-0.201, p=0.04). A similar correlation was observed in the study conducted by Fornitano LD and Godoy MF (15). They divided patients into two groups: those who achieved RPP above 30,000 (Group-A) and those below that (Group-B). Significant coronary artery involvement was observed in 48.7% of patients in Group-B compared to 24% in Group-A (Fisher-exact test; p=0.0034; Odds Ratio 0.3327).

Exercise capacity measured in METs has a strong correlation with future cardiovascular events, with higher workloads predicting improved survival rates (12). Exercise capacity above 10 METs was associated with low mortality, even in patients with significant CAD (12). In addition to the primary objective, the study also found a negative correlation between the METs attained, duration of exercise, and the SYNTAX score. In another study involving 122,007 consecutive patients undergoing exercise stress testing, patients with the highest functional capacity were associated with the lowest risk-adjusted all-cause mortality (16).

The present study was able to demonstrate that patients with diabetes had more severe CAD as assessed by the SYNTAX Score. Earlier studies have suggested that the overall prevalence and prognosis of CAD in diabetes are high (17). The severity of CAD was found to be high in diabetes when compared to the non-diabetic population (18). In a study by Srinivasan MP et al., it was observed that patients with diabetes of more than five years had more severe disease than non-diabetics (19). Findings from the study by Shaw LJ et al. demonstrated angiographically more severe disease in diabetic patients than in non-diabetic controls (14).


Selection bias in cases as it was a single-center study and it may not reflect the trend in the community. Larger multicenter community-based studies are needed. Although a negative correlation was obtained between RPP and the SYNTAX score, a specific cut-off value above which the absolute risk increased could not be defined. Larger multicenter community-based studies in the future may overcome these limitations.


The exercise ECG test is a useful and cost-effective investigation for the evaluation of CAD, and the diagnostic value may be enhanced by analysing the DTS and RPP. The study demonstrated a negative correlation between DTS, RPP, and the complexity of coronary anatomy assessed by the SYNTAX score. Diabetic patients had more severe CAD with a significantly high SYNTAX score compared to the non-diabetic population. There was also a negative correlation between exercise duration, METs achieved, and the SYNTAX score in coronary angiogram.


Vaidya GN, Application of exercise ECG stress test in the current high cost modern-era healthcare system, Indian Heart J. 2017;69(4):551-55. [crossref][PubMed]
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DOI and Others

DOI: 10.7860/JCDR/2023/63982.18325

Date of Submission: Mar 09, 2023
Date of Peer Review: Apr 27, 2023
Date of Acceptance: Aug 03, 2023
Date of Publishing: Sep 01, 2023

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

• Plagiarism X-checker: Mar 18, 2023
• Manual Googling: May 24, 2023
• iThenticate Software: Jul 31, 2023 (15%)

ETYMOLOGY: Author Origin


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