Improving the positive predictive value of exercise testing in women for coronary artery disease

The exercise treadmill test (ETT) in women has been limited by a low positive predictive value (PPV) for coronary artery disease (CAD). However, the reliability of previous studies was unsatisfactory because of the inclusion of younger women with a low prevalence of CAD. To further evaluate the diagnostic properties of the ETT in women, we evaluated a group of women with chest pain who had a positive ETT result and subsequent coronary angiography. Of the 111 women, 56 had significant CAD on angiogram, yielding a PPV of 51% for the group. However, inclusion in the analysis of several pretest attributes and specific exercise test responses improved the PPV of the ETT. Age had a major effect, with the youngest group (35 to 50 years old) having a PPV of 36% compared to 68% in the oldest group (>65 years old). Several specific exercise responses (ST-segment depression >2 mm and delayed ST-segment recovery >3.0 minutes) further separated true from false positives across all age groups, increasing the PPV to approximately 80%. Onset of ischemia at a relatively low cardiac workload of <80% maximum predicted heart rate was not a significant predictor. In conclusion, the standard ETT should remain the test of choice in ambulatory women with chest pain and no significant abnormalities on baseline electrocardiogram especially in those >65 years of age.