Explainable advanced electrocardiography at rest for ruling out myocardial ischemia on stress echocardiography
Kevin X Yang1, Johan von Scheele2, Maren Maanja2
1Kolling Institute, Royal North Shore Hospital, and Faculty of Medicine and Health, University of Sydney, Sydney, Australia; St Vincent's Clinical School, University of New South Wales, Sydney, Australia.
Insights
A new advanced electrocardiography (A-ECG) score effectively identifies inducible myocardial ischemia, showing high accuracy for ruling out the condition in low-intermediate risk patients with stable chest pain. This score aids in selecting appropriate patients for stress echocardiography (SE).
Area of Science:
- Cardiology
- Diagnostic Imaging
- Electrocardiography
Background:
- Stress echocardiography (SE) is resource-intensive for diagnosing coronary artery disease (CAD) in low-intermediate risk patients.
- A need exists for non-invasive methods to identify inducible myocardial ischemia in this population.
Purpose of the Study:
- To develop and validate a resting advanced electrocardiography (A-ECG) score.
- To assess the diagnostic performance of the A-ECG score for detecting inducible myocardial ischemia on SE.
Main Methods:
- A multivariable logistic regression model was used to derive the A-ECG score.
- The score was applied retrospectively to resting 12-lead ECGs of patients with low-intermediate risk stable chest pain.
Main Results:
- The 3-parameter A-ECG score demonstrated good diagnostic performance (AUC 0.85).
- It showed high sensitivity (92%) and an excellent negative predictive value (99%) for inducible myocardial ischemia.
- The score had a specificity of 67%.
Conclusions:
- The A-ECG score is a valuable tool for assessing inducible myocardial ischemia in low-intermediate risk patients.
- It can help triage patients, improving the selection for further testing with SE.
- The score's high negative predictive value is particularly useful for ruling out ischemia.
Background:
Stress echocardiography (SE) is relatively resource intensive and has a low incidence of abnormal tests for detecting coronary artery disease (CAD) in low-to-intermediate risk patients. This study aimed to derive and determine the diagnostic performance of a resting advanced electrocardiography (A-ECG) score for detecting inducible myocardial ischemia on SE in patients with low-to-intermediate risk stable chest pain.
Methods:
Patients were included if they presented with low-to-intermediate risk stable chest pain to the emergency department, had acute coronary syndrome ruled out by electrocardiography (ECG) and high-sensitivity troponin, and subsequently underwent outpatient SE. Patients were excluded if they had known CAD or confounders on resting ECG. A-ECG was retrospectively applied to a standard resting 12‑lead ECG and a multivariable logistic regression score was derived to predict myocardial ischemia on SE.
Results:
Among 292 patients (51 % male, age 58 ± 14 years), 24 (8 %) exhibited inducible myocardial ischemia on SE. A 3-parameter A-ECG score had an area under the receiver-operating characteristic curve (AUC [bootstrapped 95 % confidence interval]) of 0.85 [0.75-0.93], sensitivity 92 [67-100]%, specificity 67 [64-94]%, positive predictive value 22 [20-55]%, negative predictive value 99 [96-100]%, positive likelihood ratio 2.8 [2.5-12.0] and inverse negative likelihood ratio 8.1 [2.5-18.0].
Conclusions:
An A-ECG score had a good overall diagnostic performance and excellent performance for ruling out inducible myocardial ischemia on SE. This supports the use of an A-ECG score to triage and improve the selection of patients with low-intermediate risk stable chest pain that should undergo further testing with SE.
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