Comparative effectiveness of exercise electrocardiography versus exercise echocardiography in women presenting with suspected coronary artery disease: a randomized study

Abstract

Objective There is a paucity of randomised diagnostic studies in women with suspected coronary artery disease(CAD). This study sought to assess the relative value of exercise stress echocardiography (ESE) compared with exercise ECG (Ex-ECG) in women with CAD. Methods Accordingly, 416 women with no prior CAD and intermediate probability of CAD (mean pre-test probability 41%), were randomized to undergo either Ex-ECG or ESE. The primary endpoints were the positive predictive value (PPV) for the detection of significant CAD and downstream resource utilisation. Results The PPV of ESE and Ex-ECG were 33% and 30% (p = 0.87) respectively for the detection of CAD. There were similar clinic visits (36 vs 29, p = 0.44) and emergency visits with chest pain (28 vs 25, p = 0.55) in the Ex-ECG and ESE arms respectively. At 2.9 years,cardiac events were 6 Ex-ECG vs 3 ESE, p = 0.31. Although initial diagnosis costs were higher for ESE, more women underwent further CAD testing in the Ex-ECG arm compared to the ESE arm (37 vs 17, p = 0.003). Overall, there was higher downstream resource utilisation (hospital attendances and investigations) in the Ex-ECG arm (p=0.002). Using National Health Service tariffs 2020/21 (British pounds) the cumulative diagnostic costs were 7.4% lower for Ex-ECG compared with ESE, but this finding is sensitive to the cost differential between ESE and Ex-ECG. Conclusion In intermediate-risk women who are able to exercise, Ex-ECG had similar efficacy to an ESE strategy, with higher resource utilisation whilst providing cost savings.

Gender Disparities in Cardiovascular Disease and Their Management: A Review

“…The gender difference in HF risk, first shown in the Framingham Heart Study, was that men were two times more likely to have heart failure (P < 0.05), compared with five times in women with the respective nondiabetic population (P < 0.01) [30].…”

Sixty years of the Bruce protocol: reappraising the contemporary role of exercise stress testing with electrocardiographic monitoring

“…Some hindrances should be acknowledged when considering the use of ExECG in the assessment of suspected CAD. 16 , 57 , 63 , 68 , 69 First, technical issues such as ECG quality or baseline abnormalities (including left bundle branch block or ventricular pacing, both of which could affect interpretation) should be considered. 26 , 52 , 57 Second, the use of medications (namely anti-ischemic agents) as well as pathologies such as anemia and valvular heart disease may influence repolarization findings.…”

“… 17 , 70 , 71 Third, there are still some questions regarding the overall use of ExECG in different subgroups. 68 , 69 , 71 Although different studies support the added value of imaging in the face of ExECG, two randomized controlled trials showed that in women at low and moderate risk (respectively), an ExECG-based strategy provided similar efficacy to one based on imaging (with nuclear and echocardiographic assessments, respectively). 63 - 65 , 68 , 69 Finally, data have emerged showing that ECG abnormalities may be associated with an increased risk of events in those with normal imaging findings.…”

“… 68 , 69 , 71 Although different studies support the added value of imaging in the face of ExECG, two randomized controlled trials showed that in women at low and moderate risk (respectively), an ExECG-based strategy provided similar efficacy to one based on imaging (with nuclear and echocardiographic assessments, respectively). 63 - 65 , 68 , 69 Finally, data have emerged showing that ECG abnormalities may be associated with an increased risk of events in those with normal imaging findings. 72 , 73 Although further data are needed to fully clarify these findings, and the fact that factors such as functional capacity and BP should also be equated, these, however, show that there are still unmet issues relating to this technique.…”