Alternative diagnostic strategies for coronary artery disease in women: demonstration of the usefulness and efficiency of probability analysis.

Abstract

Alternative strategies using conditional probability analysis for the diagnosis of coronary artery disease (CAD) were examined in 93 infarct-free women presenting with chest pain. Another group of 42 consecutive female patients was prospectively analyzed. For this latter group, the physician had access to the pretest and posttest probability of CAD before coronary angiography. These 135 women all underwent stress electrocardiographic, thallium scintigraphic, and coronary angiographic examination. The pretest and posttest probabilities of coronary disease were derived from a computerized Bayesian algorithm. Probability estimates were calculated by the four following hypothetical strategies: SO, in which history, including risk factors, was considered; S 1, in which history and stress electrocardiographic results were considered; S2, in which history and stress electrocardiographic and stress thallium scintigraphic results were considered; and S3, in which history and stress electrocardiographic results were used, but in which stress scintigraphic results were considered only if the poststress probability of CAD was between 10% and 90%, i.e., if a sufficient level of diagnostic certainty could not be obtained with the electrocardiographic results alone. The strategies were compared with respect to accuracy with the coronary angiogram as the standard. For both groups of women, S2 and S3 were found to be the most accurate in predicting the presence or absence of coronary disease (p < .05). However, it was found with use of S3 that more than one-third of the thallium scintigrams could have been avoided without loss of accuracy. It was also found that diagnostic catheterization performed to exclude CAD as a diagnosis could have been avoided in half of the patients without loss of accuracy. Studies in the prospective group of 42 women confirmed that S2 and S3 had the best diagnostic accuracy. We also observed a higher prevalence of angiographically documented coronary disease in this group (48% vs 26% in the first group of 93 women). In this prospectively studied group, there was a smaller proportion of patients with a low probability estimate of CAD (29% of the patients with a probability of .10% in the prospective group vs 58% of the patients in the first group). Our results suggest that the treating physician's prior knowledge of probability estimates reduced the number of unnecessary diagnostic coronary angiographic procedures performed. Circulation 71, No. 3, 535-542, 1985. THE APPLICATION of probability methods to the diagnosis of coronary artery disease (CAD) is an important conceptual advance. IA The validity of probability analysis for diagnosing CAD has already been demonstrated by comparison of the calculated probability of disease with coronary angiographic results.5-10 Another potential application of probability analysis is to

Selection of patients for myocardial perfusion scintigraphy based on fuzzy sets theory applied to clinical-epidemiological data and treadmill test results

“…This modification in the score derived from Framingham study database was made to integrate the chest pain criterion into the score and to adjust it to the characteristics of our patient population. This adjustment consisted of assigning different points to some of the risk factors and was based on a previous analysis (oral presentation, "V Simpósio Ibero-Americano de Cardiologia Nuclear", Florianópolis, December [5][6][7]2002). The final score used here ranges from -8 to 26 and is presented in Table 1.…”

“…Many investigators have demonstrated that the appropriate diagnostic applications of MPS are for patients who have an intermediate likelihood of disease (2)(3)(4)(5)(6). It has been suggested (6) that patients with a low likelihood of disease might not be tested or might simply undergo the TT.…”

Guía sobre el manejo de la angina estable. Versión resumida

“…A pesar de sus limitaciones en la mujer, se ha demostrado que la realización del ECG de esfuerzo reduce el número de pruebas diagnósticas sin que haya pérdida de precisión diagnóstica. De hecho, en sólo un 30% de las mujeres (aquellas en las que no se alcanzó el diagnóstico de CI o se lo excluyó con certeza) es preciso realizar otras pruebas 282 . Aunque aún está por definir la estrategia óptima para el diagnóstico de la CI en la mujer, el Grupo de Trabajo considera que no existe evidencia suficiente que haga recomendable sustituir en todas las mujeres en estudio por posible CI la ergometría convencional por las técnicas de imagen con estrés.…”

Indicação de cintilografia de perfusão do miocárdio para a detecção de doença arterial coronariana, baseada em evidências ergométricas e clínico-epidemiológicas

“…Several research groups have published studies proposing algorithms aimed at establishing the best diagnostic strategy for CAD [8][9][10][11][12] .…”

“…However, this is an expensive diagnostic method and must be utilized when the analysis of the clinical-epidemiological factors and results of the treadmill test do not significantly decrease the probability of obstructive coronary disease [8][9][10][11][12] . Therefore, it is important to define objective criteria, based on the analysis of clinical-epidemiological factors as well as the results of the treadmill test, which can be used to indicate the necessity of performing a myocardial perfusion scintigraphy.…”