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Title: Incremental value of clinical assessment, supine exercise electrocardiography, and biplane exercise radionuclide ventriculography in the prediction of coronary artery disease in men with chest pain

Abstract

The incremental value of clinical assessment, exercise electrocardiography (ECG) and biplane radionuclide ventriculography (RVG) in the prediction of coronary artery disease (CAD) was assessed in 105 men without myocardial infarction who were undergoing coronary angiography for investigation of chest pain. Independent clinical assessment of chest pain was made prospectively by 2 physicians. Graded supine bicycle exercise testing was symptom-limited. Right anterior oblique ECG-gated first-pass RVG and left anterior oblique ECG-gated equilibrium RVG were performed at rest and exercise. Regional wall motion abnormalities were defined by agreement of 2 of 3 blinded observers. A combined strongly positive exercise ECG response was defined as greater than or equal to 2 mm ST depression or 1.0 to 1.9 mm ST depression with exercise-induced chest pain. A multivariate logistic regression model for the preexercise prediction of CAD was derived from the clinical data and selected 2 variables: chest pain class and cholesterol level. A second model assessed the incremental value of the exercise test in prediction of CAD and found 2 exercise variables that improved prediction: RVG wall motion abnormalities, and a combined strongly positive ECG response. Applying the derived predictive models, 37 of the 58 patients (64%) with preexercise probabilities of 10 tomore » 90% crossed either below the 10% probability threshold or above the 90% threshold and 28 (48%) also moved across the 5 and 95% thresholds. Supine exercise testing with ECG and biplane RVG together, but neither test alone, effectively adds to clinical prediction of CAD. It is most useful in men with atypical chest pain and when the ECG and RVG results are concordant.« less

Authors:
; ; ; ; ; ;
Publication Date:
Research Org.:
Alfred Hospital, Melbourne, Australia
OSTI Identifier:
5077245
Resource Type:
Journal Article
Resource Relation:
Journal Name: Am. J. Cardiol.; (United States); Journal Volume: 52:8
Country of Publication:
United States
Language:
English
Subject:
62 RADIOLOGY AND NUCLEAR MEDICINE; BLOOD VESSELS; SCINTISCANNING; CARDIOVASCULAR DISEASES; FORECASTING; HEART; BLOOD FLOW; DYNAMIC FUNCTION STUDIES; EXERCISE; MATHEMATICAL MODELS; PATIENTS; TECHNETIUM ISOTOPES; BODY; CARDIOVASCULAR SYSTEM; COUNTING TECHNIQUES; DIAGNOSTIC TECHNIQUES; DISEASES; ISOTOPES; ORGANS; RADIOISOTOPE SCANNING; 550601* - Medicine- Unsealed Radionuclides in Diagnostics

Citation Formats

Currie, P.J., Kelly, M.J., Harper, R.W., Federman, J., Kalff, V., Anderson, S.T., and Pitt, A. Incremental value of clinical assessment, supine exercise electrocardiography, and biplane exercise radionuclide ventriculography in the prediction of coronary artery disease in men with chest pain. United States: N. p., 1983. Web. doi:10.1016/0002-9149(83)90507-6.
Currie, P.J., Kelly, M.J., Harper, R.W., Federman, J., Kalff, V., Anderson, S.T., & Pitt, A. Incremental value of clinical assessment, supine exercise electrocardiography, and biplane exercise radionuclide ventriculography in the prediction of coronary artery disease in men with chest pain. United States. doi:10.1016/0002-9149(83)90507-6.
Currie, P.J., Kelly, M.J., Harper, R.W., Federman, J., Kalff, V., Anderson, S.T., and Pitt, A. 1983. "Incremental value of clinical assessment, supine exercise electrocardiography, and biplane exercise radionuclide ventriculography in the prediction of coronary artery disease in men with chest pain". United States. doi:10.1016/0002-9149(83)90507-6.
@article{osti_5077245,
title = {Incremental value of clinical assessment, supine exercise electrocardiography, and biplane exercise radionuclide ventriculography in the prediction of coronary artery disease in men with chest pain},
author = {Currie, P.J. and Kelly, M.J. and Harper, R.W. and Federman, J. and Kalff, V. and Anderson, S.T. and Pitt, A.},
abstractNote = {The incremental value of clinical assessment, exercise electrocardiography (ECG) and biplane radionuclide ventriculography (RVG) in the prediction of coronary artery disease (CAD) was assessed in 105 men without myocardial infarction who were undergoing coronary angiography for investigation of chest pain. Independent clinical assessment of chest pain was made prospectively by 2 physicians. Graded supine bicycle exercise testing was symptom-limited. Right anterior oblique ECG-gated first-pass RVG and left anterior oblique ECG-gated equilibrium RVG were performed at rest and exercise. Regional wall motion abnormalities were defined by agreement of 2 of 3 blinded observers. A combined strongly positive exercise ECG response was defined as greater than or equal to 2 mm ST depression or 1.0 to 1.9 mm ST depression with exercise-induced chest pain. A multivariate logistic regression model for the preexercise prediction of CAD was derived from the clinical data and selected 2 variables: chest pain class and cholesterol level. A second model assessed the incremental value of the exercise test in prediction of CAD and found 2 exercise variables that improved prediction: RVG wall motion abnormalities, and a combined strongly positive ECG response. Applying the derived predictive models, 37 of the 58 patients (64%) with preexercise probabilities of 10 to 90% crossed either below the 10% probability threshold or above the 90% threshold and 28 (48%) also moved across the 5 and 95% thresholds. Supine exercise testing with ECG and biplane RVG together, but neither test alone, effectively adds to clinical prediction of CAD. It is most useful in men with atypical chest pain and when the ECG and RVG results are concordant.},
doi = {10.1016/0002-9149(83)90507-6},
journal = {Am. J. Cardiol.; (United States)},
number = ,
volume = 52:8,
place = {United States},
year = 1983,
month =
}
  • The sensitivity of the commonly used stress tests for the diagnosis of coronary artery disease was analyzed in 46 patients with significant occlusion (greater than or equal to 70% luminal diameter obstruction) of only one major coronary artery and no prior myocardial infarction. In all patients, thallium-201 perfusion imaging (both planar and seven-pinhole tomographic) and 12 lead electrocardiography were performed during the same graded treadmill exercise test and radionuclide angiography was performed during upright bicycle exercise. Exercise rate-pressure (double) product was 22,307 +/- 6,750 on the treadmill compared with 22,995 +/- 5,622 on the bicycle (p = NS). Exercise electrocardiogramsmore » were unequivocally abnormal in 24 patients (52%). Qualitative planar thallium images were abnormal in 42 patients (91%). Quantitative analysis of the tomographic thallium images were abnormal in 41 patients (89%). An exercise ejection fraction of less than 0.56 or a new wall motion abnormality was seen in 30 patients (65%). Results were similar for the right (n = 11) and left anterior descending (n = 28) coronary arteries while all tests but the planar thallium imaging showed a lower sensitivity for isolated circumflex artery disease (n = 7). The specificity of the tests was 72, 83, 89 and 72% for electrocardiography, planar thallium imaging, tomographic thallium imaging and radionuclide angiography, respectively. The results suggest that exercise thallium-201 perfusion imaging is the most sensitive noninvasive stress test for the diagnosis of single vessel coronary artery disease.« less
  • Patients with mitral valve prolapse (MVP) frequently experience chest pain which may, especially in older subjects and males, be difficult to differentiate from angina pectoris. Electrocardiographic (ECG) changes, ventricular arrhythmias, metabolic abnormalities and rare reports of myocardial infarction and sudden death further suggest the presence of an ischemic process in these patients. The recognition of accompanying coronary artery disease (CAD) and exclusion of other causes of ischemia, therefore, may be important in determining the prognosis and appropriate therapy for such patients. We performed stress ECGs and perfusion scintigrams in 25 patients with confirmed MVP who underwent cardiac catheterization for evaluationmore » of chest pain. Stress ECGs were not helpful in diagnosing assosiated CAD, primarily because of a high incidence (53%, 10/19) of false positive tests, and had only a 48% overall accuracy. Scintigraphy was more accurate (p < 0.001), correctly classifying all patients. Scintigraphy was uniformly negative in patients with normal coronary arteriograms, suggesting that ischemia, if present as the cause of chest pain and ECG changes, must be either very localized or generalized.« less
  • Exercise electrocardiography and thallium scanning were performed a mean of 24 days after uncomplicated acute myocardial infarction in 103 patients, aged 36 to 60 years, who also underwent coronary angiography. The purpose of the study was to determine the ability of the noninvasive tests to predict multivessel coronary artery disease (CAD) and prognosis. Patients were followed up to document medical complications (incidence 12%: 3 deaths, 1 resuscitated cardiac arrest, 4 recurrent infarctions, 4 admissions with unstable angina) and combined events (medical events or bypass surgery, incidence 23%). The sensitivity, specificity and predictive accuracy for predicting multivessel CAD were 64%, 77%more » and 64% for a positive exercise electrocardiographic (ECG) response, 64%, 88% and 80% for a remote thallium defect, and 42%, 96% and 88% for a combination of the 2 tests. With 2 tests yielding negative findings the probability of multivessel CAD was 13%. No variable (positive exercise ECG response, remote thallium defect and presence of multivessel CAD) predicted medical events, although there were nonsignificant trends to more events in patients with any of those findings. The relative risk of combined events was 2.5 (p less than 0.05) for a positive exercise ECG response; 1.8 (NS) for a remote thallium defect; 2.6 (p less than 0.05) for multivessel CAD; and 3.1 (p less than 0.025) for both positive ECG response and remote defect. A combination of exercise electrocardiography and thallium scanning early after acute myocardial infarction helps to identify subsets of patients with high and low probabilities of multivessel CAD and combined medical or surgical events.« less
  • The ability of radionuclide variables obtained at rest and at peak exercise to discriminate the number of stenosed (greater than or equal to 70% luminal diameter narrowing) major coronary arteries was evaluated in 296 patients undergoing supine exercise radionuclide ventriculography. Stepwise linear discriminant analysis of the data from the first 200 patients identified a significant (p less than 0.001) discriminatory combination. Application of this function to the remaining 96 patients provided correct classification of arteriographically determined zero, one, two, and three stenosed arteries in 59%, 18%, 14%, and 60% of cases, respectively. The discriminant function classified minimal stenoses (zero ormore » one artery) and multivessel stenoses (two or three arteries) correctly by arteriography in two thirds of cases in each group. Arteriographic presence of three stenoses was unlikely in those classified as having no stenosis, and absence of stenosis was rare in those classified as having three stenoses. Exercise radionuclide ventriculography is most helpful in identifying minimal and multivessel coronary disease rather than number of stenosed major coronary arteries.« less
  • Two-dimensional echocardiography (2-D echo) was performed in 73 patients evaluated for coronary artery disease (CAD) and in four normal volunteers before and immediately after a maximal treadmill exercise test. Diagnostic images were obtained from the apical and parasternal windows. In 17 patients with normal coronary arteriograms, ejection fraction (EF) increased from 66 +/- 9% (+/- SD) at rest to 73 +/- 8% after exercise (p less than 0.001), while in 56 patients with proved CAD, EF fell from 56 +/- 13% at rest to 53 +/- 16% after exercise (p less than 0.01). The sensitivity of postexercise 2-D echo formore » detecting CAD (based on abnormal EF response and/or regional dyssynergy) was 91% (51 of 56 patients) and the specificity was 88% (15 of 17). Sensitivity for one-, two- and three-vessel disease was 64% (seven of 11), 95% (20 of 21) and 100%, respectively. Patients with multivessel disease showed a significant fall in a wall motion score index, from 0.79 +/- 0.25 to 0.63 +/- 0.26. Exercise radionuclide ventriculography (RNV) was also performed in 41 of the subjects (17 normals and 24 CAD patients) on a bicycle ergometer. The overall sensitivity of 2-D echo in this subgroup was 92%, compared with 71% for RNV. The sensitivity of 2-D echo for one-vessel disease (n . 4) was 50%, that for two-vessel disease (n . 12) was 100% and that for three-vessel disease (n . 12) was 100%. Respective values for RNV were 0%, 80% and 90%. The specificity of 2-D echo was 88% and that of RNV was 82%. A significantly higher peak heart rate response was observed on the treadmill than on the bicycle ergometer in both CAD patients and normal subjects. We conclude that postexercise 2-D echo is a clinically applicable technique for the diagnosis and evaluation of CAD patients and compares favorably with exercise RNV.« less