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Are the American College of Cardiology/American Heart Association guidelines for exercise testing for suspected
1Section of Cardiology, Department of Medicine, West Virginia University School of Medicine, Morgantown 26506, USA. amorise@pol.net
Insights
Exercise ECG testing is recommended for intermediate pretest probability patients with suspected coronary disease. While beneficial for intermediate groups, its utility varies across low and high probability patients, guiding clinical decisions.
Area of Science:
- Cardiology
- Diagnostic Testing
- Clinical Guidelines
Background:
- Current American College of Cardiology (ACC)/American Heart Association (AHA) guidelines recommend exercise ECG for suspected coronary disease with intermediate pretest probability.
- Patients with low or high pretest probability are generally not advised to undergo exercise ECG based on these guidelines.
Purpose of the Study:
- To evaluate the diagnostic performance and clinical utility of exercise ECG in patients with suspected coronary disease across different pretest probability groups.
- To assess the incremental value of exercise ECG in refining risk stratification for coronary artery disease.
Main Methods:
- A cohort of 872 patients with suspected coronary disease who underwent coronary angiography post-exercise ECG was analyzed.
- Patients were stratified into low, intermediate, and high pretest probability groups using a validated score (age, gender, symptoms, risk factors).
- Receiver operating characteristic (ROC) curve analysis was used to compare test performance, and predictive values were calculated for each group.
Main Results:
- Excluding inadequate tests, overall sensitivity was 70% and specificity 66%.
- Significant incremental value was observed only in the intermediate pretest probability group (pretest 70% vs. posttest 79%).
- Positive predictive value increased progressively (21% to 92%), while negative predictive value decreased (94% to 28%) from low to high probability groups.
Conclusions:
- The study confirms ACC/AHA guideline recommendations for exercise ECG selection based on pretest probability.
- Exercise ECG offers high negative predictive value for low-probability patients but may be insufficient for intermediate-probability patients due to false negatives.
- High-probability patients should primarily undergo coronary angiography, unless prognosis assessment is the goal of exercise testing.
Background:
Recently published American College of Cardiology (ACC)/American Heart Association (AHA) guidelines state that patients with suspected coronary disease and an intermediate pretest probability are appropriate candidates for exercise ECG, while those with low or high pretest probability are not.
Methods:
From 5,103 consecutive patients with symptoms of suspected coronary disease, we evaluated 872 patients who underwent coronary angiography following exercise ECG. Differences in test performance were determined using receiver operating characteristic curve area analysis. A score using age, gender, symptoms, and risk factors was used to classify patients into low, intermediate, and high pretest probability groups.
Results:
When patients with inadequate exercise tests were excluded, overall sensitivity and specificity were 70% and 66%, respectively. Only the intermediate pretest probability group demonstrated significant incremental value: pretest vs posttest intermediate, 70 +/- 3 vs 79 +/- 3 (p < 0.0001); low, 71 +/- 6 vs 76 +/- 7 (p = 0.39); and high, 69 +/- 8 vs 75 +/- 7 (p = 0.12). From the low- to the high-probability groups, there was a progressive increase in positive predictive value (21%, 62%, and 92%) and decrease in negative predictive value (94%, 72%, and 28%), respectively. The frequencies of abnormal exercise ECGs were lower in the unselected groups compared with the angiography groups (low, 13% vs 36%; intermediate, 22% vs 53%; high, 36% vs 63%).
Conclusions:
Based on the information added by exercise testing to clinical data, these results confirm the ACC/AHA guideline assignments for test selection. However, despite these guidelines, patients with a low pretest probability can be selected for exercise testing with the knowledge that a positive result is infrequent and a negative result carries a very high negative predictive value. Intermediate-probability patients on average carry a significant false-negative rate, suggesting that exercise ECG alone may not be a sufficient screening test in all intermediate-probability patients. Because of poor negative predictive value and a large percentage of negative tests, high-probability patients should undergo coronary angiography as the initial strategy, unless the goal of exercise testing is to assess prognosis.