Comparative effectiveness of exercise electrocardiography versus exercise echocardiography in women presenting with
Sothinathan Gurunathan1,2,3, Mayooran Shanmuganathan1, Ankur Chopra1
1Department of Cardiology, Northwick Park Hospital, Harrow, UK.
Insights
Exercise electrocardiography (Ex-ECG) showed similar diagnostic value to exercise stress echocardiography (ESE) for detecting coronary artery disease (CAD) in women. Ex-ECG resulted in higher resource use but offered cost savings.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Preventive Medicine
Background:
- Coronary artery disease (CAD) diagnosis in women lacks robust randomized studies.
- Evaluating non-invasive diagnostic strategies for suspected CAD is crucial.
Purpose of the Study:
- To compare the diagnostic accuracy and resource utilization of exercise stress echocardiography (ESE) versus exercise electrocardiography (Ex-ECG) in women with suspected CAD.
- To assess the positive predictive value (PPV) and downstream healthcare costs associated with each diagnostic method.
Main Methods:
- A randomized study involving 416 women with intermediate pre-test probability of CAD.
- Participants were assigned to either Ex-ECG or ESE for diagnostic evaluation.
- Primary endpoints included PPV for significant CAD and resource utilization.
Main Results:
- The PPV for detecting CAD was similar between ESE (33%) and Ex-ECG (30%).
- Downstream resource utilization was higher in the Ex-ECG arm, despite lower initial diagnostic costs.
- Cardiac events were comparable, with 6 in the Ex-ECG group versus 3 in the ESE group over 2.9 years.
Conclusions:
- In intermediate-risk women capable of exercise, Ex-ECG demonstrates comparable efficacy to ESE for CAD detection.
- Ex-ECG strategy led to higher resource utilization but resulted in overall cost savings.
- The choice between Ex-ECG and ESE may depend on healthcare system costs and resource availability.
Aims:
There is a paucity of randomized diagnostic studies in women with suspected coronary artery disease (CAD). This study sought to assess the relative value of exercise stress echocardiography (ESE) compared with exercise electrocardiography (Ex-ECG) in women with CAD.
Methods And Results:
Accordingly, 416 women with no prior CAD and intermediate probability of CAD (mean pre-test probability 41%), were randomized to undergo either Ex-ECG or ESE. The primary endpoints were the positive predictive value (PPV) for the detection of significant CAD and downstream resource utilization. The PPV of ESE and Ex-ECG were 33% and 30% (P = 0.87), respectively for the detection of CAD. There were similar clinic visits (36 vs. 29, P = 0.44) and emergency visits with chest pain (28 vs. 25, P = 0.55) in the Ex-ECG and ESE arms, respectively. At 2.9 years, cardiac events were 6 Ex-ECG vs. 3 ESE, P = 0.31. Although initial diagnosis costs were higher for ESE, more women underwent further CAD testing in the Ex-ECG arm compared to the ESE arm (37 vs. 17, P = 0.003). Overall, there was higher downstream resource utilization (hospital attendances and investigations) in the Ex-ECG arm (P = 0.002). Using National Health Service tariffs 2020/21 (British pounds) the cumulative diagnostic costs were 7.4% lower for Ex-ECG compared with ESE, but this finding is sensitive to the cost differential between ESE and Ex-ECG.
Conclusion:
In intermediate-risk women who are able to exercise, Ex-ECG had similar efficacy to an ESE strategy, with higher resource utilization whilst providing cost savings.
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