Analysis of multiple noninvasive test procedures for the diagnosis of coronary artery disease

Abstract

All noninvasive tests used for the diagnosis of coronary artery disease are imperfect, both in sensitivity and in specificity. Accordingly, we evaluated the accuracy of four different diagnostic tests in various combinations in a population of 43 patients undergoing coronary angiography to determine if accuracy could be improved by multiple testing. These tests included stress electrocardiography for evaluation of exercise‐induced ST‐segment depression, stress cardio‐kymography (CKG) for detection of exercise‐induced precordial regional left ventricular dysfunction, stress 201thallium scintigraphy for assessment of exercise‐induced regional myocardial hypoperfusion, and cardiac fluoroscopy for detection of coronary artery calcification. A total of 46 (27%) of the 172 test responses observed were incorrect relative to angiography. These “false” responses were uniformly distributed over the four test procedures (12 ECG, 11 CKG, 10 201thallium, 13 fluoroscopy). Thus, a single test had a limited predictive accuracy for the detection or exclusion of coronary artery disease. The greater the number of abnormal responses observed in a given patient the greater the predictive accuracy for disease, especially multi‐vessel disease. Analysis of various combinations of these procedures revealed substantial differences both in cost of testing and net diagnostic yield. These data suggest that the four procedures employed are functionally independent and highly accurate relative to the diagnosis of coronary artery disease when used in combination. Cost‐effectiveness of diagnostic testing might be improved with the use of combinations of the less expensive and more accurate of these tests.

Cost analysis of combining congenital cardiac catheterization and electrophysiology procedures in an outpatient setting

“…Cost reduction has been seen in combining noninvasive tests as well. For patients who needed multiple noninvasive tests for coronary artery disease diagnosis, combining fluoroscopy, stress electrogram, and stress thallium scintigraphy optimized the cost per diagnostic yield of the tests . It is important to note that combining these tests was not cost‐efficient if all tests were not required.…”

Cardiokymography

“…In addition, the reference standard is expressed as significant disease in any of the 3 major coronary arteries (greater than or equal to 50% narrowing of luminal diameter). The results of the 5 available studies (1)(2)(3)(4)(5) demonstrate that cardiokymography has a sensitivity of 72% and specificity of 90% (Table 1) a value superior to the exercise ECG (sensitivity = 65%, specificity = 85%) but similar to thallium-201 myocardial scintigraphy (sensitivity = 85%, specificity = 84%) in comparable subjects (6). There does not seem to be a large change in these figures after patients with previous myocardial infarction are excluded from the analysis.…”

Management of coexistent carotid artery and coronary artery disease.

“…Patients with stable mild angina pectoris or asymptomatic patients undergo stress electrocardiography with thallium-201 perfusion scintigraphy. Using noninvasive methods, Charuzi et al 15 confirmed a 79% sensitivity and specificity for multivessel atherosclerotic coronary artery involvement among all patients undergoing stress electrocardiography.…”