Reassessing the value of the exercise electrocardiogram in the diagnosis of stable chest pain
Author(s)
Bourdillon, PJ
Type
Chapter
Abstract
Background: doubt has been expressed about the value of exercise electrocardiography (ECG) in the diagnosis of coronary artery disease (CAD). This paper tests the diagnostic impact of 2 strategies for analysing ST segment depression.
Methods: 7739 consecutive patients referred to a rapid access chest pain clinic from primary care between January 1999 and March 2010 were studied. The pre-exercise probability of coronary artery disease (pCAD) was determined from symptoms and risk factors using the methodology of the UK National Institute for Health and Clinical Excellence (NICE). The post-exercise pCAD was calculated: firstly, using NICE’s sensitivity of 67% and specificity of 69% for the exercise ECG, and secondly using a published set of 6 sensitivities and specificities that vary according to the amount of ST segment shift on exercise. Pre- and post-exercise pCADs were grouped according to NICE’s categories: CAD ruled out, suitable for non-invasive testing, candidate for coronary arteriography, and CAD ruled in.
Results: 2910 of the 5157 patients exercised were in the ‘suitable for non-invasive testing’ category. With NICE’s single combination of sensitivity and specificity, 793 (27.3%) of the 2910 had CAD ruled out and 128 (4.4%) became candidates for coronary arteriography. With 6 combinations of sensitivity and specificity, 1383 (47.5%) of the 2910 had CAD ruled out and 48 (1.6%) CAD ruled in, while another 170 (5.8%) became candidates for coronary arteriography.
Conclusion: the exercise ECG has considerable diagnostic value if it is assumed that the greater the ST segment shift the greater the likelihood of CAD.
Methods: 7739 consecutive patients referred to a rapid access chest pain clinic from primary care between January 1999 and March 2010 were studied. The pre-exercise probability of coronary artery disease (pCAD) was determined from symptoms and risk factors using the methodology of the UK National Institute for Health and Clinical Excellence (NICE). The post-exercise pCAD was calculated: firstly, using NICE’s sensitivity of 67% and specificity of 69% for the exercise ECG, and secondly using a published set of 6 sensitivities and specificities that vary according to the amount of ST segment shift on exercise. Pre- and post-exercise pCADs were grouped according to NICE’s categories: CAD ruled out, suitable for non-invasive testing, candidate for coronary arteriography, and CAD ruled in.
Results: 2910 of the 5157 patients exercised were in the ‘suitable for non-invasive testing’ category. With NICE’s single combination of sensitivity and specificity, 793 (27.3%) of the 2910 had CAD ruled out and 128 (4.4%) became candidates for coronary arteriography. With 6 combinations of sensitivity and specificity, 1383 (47.5%) of the 2910 had CAD ruled out and 48 (1.6%) CAD ruled in, while another 170 (5.8%) became candidates for coronary arteriography.
Conclusion: the exercise ECG has considerable diagnostic value if it is assumed that the greater the ST segment shift the greater the likelihood of CAD.
Version
Published version
Editor(s)
Gaze, David
Date Issued
2012-03
Citation
Coronary Artery Disease - Current Concepts in Epidemiology, Pathophysiology, Diagnostics and Treatment, 2012, pp.171-182
ISBN
978-953-51-0262-5
Publisher
InTech - Open Access Publisher
Source Title
Coronary Artery Disease - Current Concepts in Epidemiology, Pathophysiology, Diagnostics and Treatment
Chapter
9
Start Page
171
End Page
182
Journal / Book Title
Coronary Artery Disease - Current Concepts in Epidemiology, Pathophysiology, Diagnostics and Treatment
Copyright Statement
© 2012 The Authors
Publisher Place
Rijeka, Croatia
Subjects
Exercise Electrocardiography
National institute for Health and Clinical Excellence
Pre-test probability
Post-test probability
Stable chest pain
Place of Publication
Rijeka, Croatia
Publication Status
Published
Article Number
9