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Exercise Electrocardiogram Neither Predicts Nor Excludes Coronary Artery Disease in Women with Low to Intermediate
Remco J J Knol1,2, Huub Kan1,2, Maurits Wondergem1,2
11 Cardiac Imaging Division Alkmaar, Northwest Clinics , Alkmaar, The Netherlands .
Insights
Exercise electrocardiogram (ExECG) is unreliable for diagnosing coronary artery disease (CAD) in women. Cardiac computed tomography (cardiac-CT) may be a more appropriate diagnostic tool for excluding CAD in this patient population.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Medical Technology
Background:
- The diagnostic accuracy of exercise electrocardiogram (ExECG) for coronary artery disease (CAD) in symptomatic women with low-to-intermediate risk is debated.
- Nondiagnostic or erroneous ExECG results are common in this demographic.
- Cardiac computed tomography (cardiac-CT) is proposed as a potentially more suitable alternative for excluding CAD in women.
Purpose of the Study:
- To compare the diagnostic performance of ExECG against cardiac-CT in a cohort of female patients presenting with chest pain.
- To evaluate the utility of ExECG in detecting significant coronary artery disease (CAD) in women with low-to-intermediate risk.
Main Methods:
- A registry-based study included 551 consecutive female patients.
- ExECG and cardiac-CT were performed within one month of each other.
- Cardiac-CT results were used as the reference standard to assess ExECG performance, considering both ≥50% and ≥70% stenosis.
Main Results:
- ExECG yielded nondiagnostic results in 39% of patients.
- Cardiac-CT revealed CAD in 57% of women with a negative ExECG and in 49% of the overall cohort (21% with ≥50% stenosis).
- ExECG demonstrated low sensitivity (3.7%) and positive predictive value (7.1%) for detecting ≥50% stenosis, despite high specificity (95.7%) and NPV (91.7%).
Conclusions:
- ExECG significantly underdiagnosed CAD in women, failing to detect significant stenosis in nearly half of affected patients.
- The high rate of false positives (no CAD on cardiac-CT in 64% of positive ExECGs) questions the diagnostic strategy of ExECG in this population.
- Further prospective studies are needed to determine if replacing ExECG with cardiac-CT improves patient prognosis.
Aim:
The value of exercise electrocardiogram (ExECG) in symptomatic female patients with low to intermediate risk for significant coronary artery disease (CAD) has been under debate for many years, and nondiagnostic or even erroneous test results are frequently encountered. Cardiac-CT may be more appropriate to exclude CAD in women. This study compares the results of ExECGs with those of cardiac-CTs, performed within a time frame of 1 month in an all-comers female chest pain population.
Patients And Methods:
Five hundred fifty-one consecutive female patients from a patient registry were included. ExECGs were negative in 324 (59%), positive in 14 (3%), and nondiagnostic in 213 (39%) patients. CAD was revealed by cardiac-CT in 57% of the women with negative ExECG. No signs of CAD were present on cardiac-CT in 64% of the women with a positive ExECG. Cardiac-CT showed presence of CAD in 268/551 (49%) patients, of whom 56/268 (21%) was diagnosed with ≥50% stenosis. The ExECG of the latter group was negative in 26 (46%), inconclusive in 29 (52%), and positive in 1 (2%). Considering ≥50% stenosis at cardiac-CT as the reference, sensitivity, specificity, PPV, and NPV of ExECG for the present population were 3.7%, 95.7%, 7.1%, and 91.7%, respectively. Similar diagnostic performance was calculated when considering ≥70% stenosis at cardiac-CT as the reference.
Conclusion:
ExECG failed to detect CAD in more than half of this cohort and in almost half of women with >50% stenosis at cardiac-CT. Importantly, no CAD was detected by cardiac-CT in 64% of women with a positive ExECG. ExECG is therefore questionable as a diagnostic strategy in women with low-to-intermediate risk of CAD, although prospective studies are warranted to determine whether replacing ExECG by cardiac-CT provides better prognoses.
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