{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T02:29:02Z","timestamp":1760149742015,"version":"build-2065373602"},"reference-count":17,"publisher":"MDPI AG","issue":"17","license":[{"start":{"date-parts":[[2023,9,4]],"date-time":"2023-09-04T00:00:00Z","timestamp":1693785600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Italian Ministry of Health, Rome, Italy (Ricerca Corrente, Centro Cardiologico Monzino IRCCS)"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Many variables obtained during cardiopulmonary exercise test (CPET), including O2 uptake (VO2) versus heart rate (HR, O2-pulse) and work rate (VO2\/Watt), provide quantitative patterns of responses to exercise when left ventricular dysfunction is an effect of myocardial ischemia (MI). Therefore, CPET offers a unique approach to evaluate exercise-induced MI in the presence of fixed or dynamic coronary arteries stenosis. In this paper, we examined the case of a 74-year-old patient presenting with an ischemic CPET and a normal stress cardiac magnetic resonance (CMR) with dipyridamole. A coronary angiography demonstrated the presence of myocardial bridging (MB), a well-known congenital coronary anomaly that is able to generate MI during exercise (but not in provocative testing using coronary artery vasodilators, such as dipyridamole). Despite the good diagnostic accuracy of the imaging methods (i.e., stress CMR) in MI detection, this case shows that exercise should be the method of choice in elicit ischemia in specific cases, like MB.<\/jats:p>","DOI":"10.3390\/jcm12175764","type":"journal-article","created":{"date-parts":[[2023,9,4]],"date-time":"2023-09-04T10:24:30Z","timestamp":1693823070000},"page":"5764","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["\u201cUnder the Bridge\u201d: Looking for Ischemia in a Patient with Intramyocardial Coronary Artery Course\u2014The Role of the Cardiopulmonary Exercise Test"],"prefix":"10.3390","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9985-7407","authenticated-orcid":false,"given":"Massimo","family":"Mapelli","sequence":"first","affiliation":[{"name":"Centro Cardiologico Monzino IRCCS, Via Carlo Parea 4, 20138 Milan, Italy"},{"name":"Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, 20122 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gaia","family":"Cattadori","sequence":"additional","affiliation":[{"name":"IRCCS Multimedica, 20138 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Elisabetta","family":"Salvioni","sequence":"additional","affiliation":[{"name":"Centro Cardiologico Monzino IRCCS, Via Carlo Parea 4, 20138 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7781-1691","authenticated-orcid":false,"given":"Irene","family":"Mattavelli","sequence":"additional","affiliation":[{"name":"Centro Cardiologico Monzino IRCCS, Via Carlo Parea 4, 20138 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Emanuele","family":"Pestrin","sequence":"additional","affiliation":[{"name":"Unit\u00e0 Clinico Operativa di Clinica Medica, Universit\u00e0 degli Studi di Trieste, Piazzale Europa, 1, 34127 Trieste, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-3438-1537","authenticated-orcid":false,"given":"Umberto","family":"Attanasio","sequence":"additional","affiliation":[{"name":"Department of Translational Medical Sciences, Federico II University, Corso Umberto I 40, 80138 Naples, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Damiano","family":"Magr\u00ec","sequence":"additional","affiliation":[{"name":"Department of Clinical and Molecular Medicine, University \u201cLa Sapienza\u201d, Piazzale Aldo Moro 5, 00185 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Pietro","family":"Palermo","sequence":"additional","affiliation":[{"name":"Centro Cardiologico Monzino IRCCS, Via Carlo Parea 4, 20138 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Piergiuseppe","family":"Agostoni","sequence":"additional","affiliation":[{"name":"Centro Cardiologico Monzino IRCCS, Via Carlo Parea 4, 20138 Milan, Italy"},{"name":"Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, 20122 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2023,9,4]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1304","DOI":"10.1016\/S0195-668X(03)00210-0","article-title":"Exercise-induced myocardial ischaemia detected by cardiopulmonary exercise testing","volume":"24","author":"Belardinelli","year":"2003","journal-title":"Eur. 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Meas."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1629","DOI":"10.1136\/heartjnl-2021-320569","article-title":"Exercise oxygen pulse kinetics in patients with hypertrophic cardiomyopathy","volume":"108","author":"Mapelli","year":"2022","journal-title":"Heart"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"249","DOI":"10.1097\/01.hjr.0000189809.99353.76","article-title":"Cardiopulmonary evidence of exercise-induced silent ischaemia","volume":"13","author":"Bussotti","year":"2006","journal-title":"Eur. J. Prev. Cardiol."},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Danek, B.A., Kearney, K., and Steinberg, Z.L. (Heart, 2023). 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