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Effects of exercise test results on physician perceptions of coronary artery disease probability using a threshold
D A Wilson1, R C Detrano, K A Narahara
1Saint John's Cardiovascular Research Center, Torrance, California.
Insights
Exercise test data significantly improve physician accuracy in diagnosing coronary artery disease (CAD) and guiding decisions for coronary angiography. This study focused on physician interpretation, not computer algorithms.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Clinical Decision-Making
Background:
- Previous studies suggested limited diagnostic value of exercise electrocardiographic testing (EET) for coronary artery disease (CAD) when using computer algorithms.
- The applicability of these findings to physician-based diagnoses remained unclear.
Purpose of the Study:
- To evaluate if EET data enhance physician accuracy in detecting CAD, specifically 3-vessel or left main CAD.
- To determine if EET data influence physician decisions regarding coronary angiography.
Main Methods:
- A database of 312 patients with known clinical data, EET results, and coronary anatomy was used.
- Eight cardiologists assessed patient cases with and without EET data, providing disease probability estimates and angiography recommendations.
- Receiver-operating characteristic curves and goodness-of-fit analyses were employed.
Main Results:
- EET data improved the discrimination and calibration of physician estimates for CAD and severe CAD (3-vessel/left main).
- Physician decisions shifted based on EET data, with 43% of patients crossing individualized probability thresholds.
- The direction of threshold crossings indicated improved diagnostic accuracy, particularly for ruling out CAD.
Conclusions:
- Exercise test data demonstrably enhance physician diagnostic capabilities for coronary artery disease.
- EET aids in refining decisions for pursuing coronary angiography, improving diagnostic accuracy.
- Findings support the clinical utility of EET in physician-led CAD assessment.
Abstract:
The incremental diagnostic value of exercise electrocardiographic testing compared with clinical data alone in the diagnosis of coronary artery disease (CAD) was found to be of limited value in a previous study. That study used a computer algorithm for diagnosing disease. Thus, the strict use of the results apply only to computerized disease diagnosis rather than physicians' diagnoses. The aim of the present study was to determine whether exercise test data improve a physician's ability to detect the presence or absence of CAD and 3-vessel or left main CAD, and whether the data effect the decision to perform angiography. The study sample comprised a data base of 312 patients whose clinical data, exercise test results and coronary anatomy were known. Individual cases were presented to 8 cardiologists with and without exercise data. The cardiologists provided estimates of disease probability and were asked whether they would request coronary angiography. Receiver-operating characteristic curves and goodness-of-fit analysis showed better discrimination and calibration of the estimates for the presence of CAD and 3-vessel/left main CAD after exercise test results were known. Individualized probability thresholds for deciding whether to request angiography were determined for each physician. Forty-three percent of patients crossed greater than or equal to 1 threshold, with 64% of the crossings in the correct direction. For estimating the presence of any CAD, 84% of crossings from below to above a threshold were correct, whereas only 36% from above to below were correct. For 3-vessel/left main CAD, 36% of crossings from below to above a threshold were correct, whereas 88% from above to below were correct.(ABSTRACT TRUNCATED AT 250 WORDS)