Value of Exercise ECG for Risk Stratification in Suspected or Known CAD in the Era of Advanced Imaging Technologies

Bourque, Jamieson M.; Beller, George A.

doi:10.1016/j.jcmg.2015.09.006

Cited by 82 publications

(60 citation statements)

References 102 publications

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“…Detrano et al [11] reported a sensitivity of 68% and specificity of 77% for the detection of coronary artery disease (CAD) in a meta-analysis that included over 24,000 patients and 22 years of research. Exercise-induced ST-segment depression is considered the strongest predictor of future cardiac events along with the duration of exercise and exercise capacity [12]. The Duke Treadmill Score (DTS) is a widely accepted tool used by many clinicians providing added prognostic information by combining exercise duration and ST changes and angina during exercise [13].…”

Section: Non-invasive Imaging Modalitiesmentioning

confidence: 99%

Non-invasive assessment of low- and intermediate-risk patients with chest pain

Balfour

González

Kramer

2017

Trends in Cardiovascular Medicine

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Coronary artery disease (CAD) remains a significant global public health burden despite advancements in prevention and therapeutic strategies. Common non-invasive imaging modalities, anatomic and functional, are available for the assessment of patients with stable chest pain. Exercise electrocardiography is a long-standing method for evaluation for CAD and remains the initial test for the majority of patients who can exercise adequately with a baseline interpretable electrocardiogram. The addition of cardiac imaging to exercise testing provides incremental benefit for accurate diagnosis for CAD and is particularly useful in patients who are unable to exercise adequately and/or have uninterpretable electrocardiograms. Radionuclide myocardial perfusion imaging and echocardiography with exercise or pharmacological stress provide high sensitivity and specificity in the detection and further risk stratification of patients with CAD. Recently, coronary computed tomography angiography has demonstrated its growing role to rule out significant CAD given its high negative predictive value. Although less available, stress cardiac magnetic resonance provides a comprehensive assessment of cardiac structure and function and provides a high diagnostic accuracy in the detection of CAD. The utilization of non-invasive testing is complex due to various advantages and limitations, particularly in the assessment of low- and intermediate-risk patients with chest pain, where no single study is suitable for all patients. This review will describe currently available non-invasive modalities, along with current evidence-based guidelines and appropriate use criteria in the assessment of low- and intermediate-risk patients with suspected, stable CAD.

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Section: Non-invasive Imaging Modalitiesmentioning

confidence: 99%

Non-invasive assessment of low- and intermediate-risk patients with chest pain

Balfour

González

Kramer

2017

Trends in Cardiovascular Medicine

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“…At present, more than 10 million CAD imaging tests are being performed annually in the United States(11). Despite the high utilization and numerous options for noninvasive cardiac testing, uncertainty remains regarding the optimal testing strategies(12, 13). Multiple studies have investigated the value of ETT in comparison with non-invasive imaging modalities, however, a direct comparison of varying diagnostic strategies that employ non-invasive tests in isolation versus in succession to one another has to date not been assessed(9, 13).…”

Section: Introductionmentioning

confidence: 99%

Cost-effectiveness of diagnostic evaluation strategies for individuals with stable chest pain syndrome and suspected coronary artery disease

Min

Gilmore²,

Jones

et al. 2017

Clinical Imaging

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Purpose To determine lifetime cost-effectiveness of diagnostic evaluation strategies for individuals with stable chest pain and suspected coronary artery disease (CAD). Methods Exercise treadmill testing (ETT), stress echocardiography (SE), myocardial perfusion scintigraphy (MPS), coronary computed tomographic angiography (CCTA), and invasive coronary angiography (ICA) were assessed alone, or in succession to each other. Results Initial ETT followed by imaging wherein ETT was equivocal or unable to be performed appeared more cost-effective than any strategy employing initial testing by imaging. Conclusion As pre-test likelihood of CAD varies, different modalities including SE, CCTA, and MPS result in improved costs and enhanced effectiveness.

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“…7 Other prognostic variables derived from ExECG have proven useful for risk stratification. 8 Some findings of the study by Argulian et al 4 deserve mention and further discussion. Surprisingly, 81% (n = 922) of the patients in this cohort had stress echocardiography compared to only 19% (n = 218) who underwent SPECT MPI.…”

mentioning

confidence: 89%

Choosing exercise or pharmacologic stress imaging, or exercise ECG testing alone: How to decide

González

2017

Journal of Nuclear Cardiology

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Cardiac imaging of either myocardial perfusion or regional function, under resting and stress conditions, utilizing either nuclear cardiology or ultrasound technology, is the dominant approach to the noninvasive detection of coronary artery disease (CAD) in symptomatic patients. Prior to the advent of imaging technology that permitted assessment of myocardial perfusion and function, symptom-limited exercise electrocardiography (ExECG) alone was the test employed for detecting CAD. Multiple clinical studies showed that combining imaging with symptomlimited exercise enhanced the diagnostic and prognostic values of exercise testing, over the variables derived from ExECG. Pharmacologic stress then emerged as an alternative to exercise for imaging of patients who were deemed unable to attain a target heart rate of C85% of maximum predicted heart rate adjusted for age. Submaximal exercise decreases the sensitivity of MPI for detection of ischemia and prevents accurate measurement of extent of ischemia when present. 1With either SPECT or PET myocardial perfusion imaging (MPI), intravenously administered vasodilators such as dipyridamole, adenosine, and regadenoson substituted as stressors for exercise. These agents allowed for detection of relative flow reserve alterations between stenotic and normal coronary arteries. Dobutamine infusion was reserved for patients with bronchospasm, or those who ingested caffeine prior to testing. For stress echocardiography, dobutamine emerged as the major pharmacologic alternative to exercise stress. New ischemia-induced wall motion abnormalities constituted a positive test for ischemia. Sensitivity for CAD detection is higher, and specificity lower, for stress MPI compared to stress echocardiography. For this reason, stress echocardiography is commonly performed in patients at lower pre-test clinical risk for CAD. Conversely, with a higher sensitivity for CAD detection, stress MPI is advocated for higher risk patients with suspected or known CAD who need testing for appropriate clinical indications.Over the past few decades, the percentage of patients referred for pharmacologic stress imaging, relative to exercise imaging, has been increasing from about 30% to more than 50% of stress imaging tests. 2,3In addition, a substantial number of patients initially referred for exercise stress are being triaged to pharmacologic stress. Patients who are unable to achieve target heart rate with exercise are changed over to predominantly vasodilator stress for the injection of tracer for radionuclide imaging, or dobutamine infusion for completion of stress echocardiographic testing. Currently, patients referred for PET MPI all undergo pharmacologic stress since the positron-emitting tracers (e.g., Rb-82) approved for clinical imaging have very short half-lives, thereby precluding upright exercise testing with its inherent delay in moving patients postexercise for imaging in the positron camera.Because pharmacologic stress testing has been increasing over time, Argulian et al 4 sought to determi...

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Value of Exercise ECG for Risk Stratification in Suspected or Known CAD in the Era of Advanced Imaging Technologies

Cited by 82 publications

References 102 publications

Non-invasive assessment of low- and intermediate-risk patients with chest pain

Non-invasive assessment of low- and intermediate-risk patients with chest pain

Cost-effectiveness of diagnostic evaluation strategies for individuals with stable chest pain syndrome and suspected coronary artery disease

Choosing exercise or pharmacologic stress imaging, or exercise ECG testing alone: How to decide

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