Predictive value of the electrocardiogram exercise stress test for the presence or absence of left main disease
Saverio Tremamunno1, Nello Cambise1, Angelo Giuseppe Marino1,2
1Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.
Insights
The electrocardiogram exercise stress test (ECG-EST) can effectively rule out left main (LM) coronary artery disease (CAD) in patients with suspected obstructive CAD. Specific ECG-EST criteria identify patients at very low risk, reducing the need for invasive procedures.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Clinical Medicine
Background:
- The diagnostic utility of the electrocardiogram exercise stress test (ECG-EST) for excluding left main (LM) coronary artery disease (CAD) remains underexplored.
- LM CAD, a severe form of coronary artery disease, requires accurate and timely diagnosis.
Purpose of the Study:
- To evaluate the capability of ECG-EST in excluding LM CAD in patients presenting with angina and suspected obstructive CAD.
- To identify specific ECG-EST variables that predict the absence or presence of LM disease.
Main Methods:
- Retrospective analysis of 515 patients who underwent both ECG-EST and invasive coronary angiography (ICA) for suspected obstructive CAD.
- Assessment of individual and combined ECG-EST variables for their predictive value regarding LM disease (stenosis ≥50%).
Main Results:
- LM CAD was diagnosed in 5% of patients via ICA.
- ECG-EST showed low positive predictive values for LM CAD, with a maximum of 15% for a specific combination of ST-segment depression and test duration.
- Certain combined ECG-EST variables demonstrated very high negative predictive values, identifying patients at very low risk (≤2.5%) of LM disease.
Conclusions:
- ECG-EST can reliably identify patients with angina and suspected obstructive CAD who are at very low risk for LM disease.
- Specific ECG-EST findings, such as peak heart rate and ST-segment depression patterns, are crucial for risk stratification.
Background:
The ability of the electrocardiogram exercise stress test (ECG-EST) in excluding the presence of left main (LM) coronary artery disease (CAD) has been poorly investigated.
Methods:
We retrospectively selected patients who underwent both ECG-EST and elective invasive coronary angiography (ICA) at our Institution between January 2018 and December 2023 due to angina pain suspected of obstructive CAD. Preventively defined individual and combined ECG-EST variables suggesting no/mild myocardial ischemia were assessed as predictors of the absence of LM disease. Some ECG-EST variables suggesting extensive/severe myocardial ischemia were instead assessed as predictors of the presence of LM disease, defined as a stenosis ≥50% of the left main artery.
Results:
Overall, 515 patients were included (age 66.2 ± 11 years; 74% men). LM disease at ICA was found in 26 patients (5%). Individual and combined ECG-EST variables showed low positive predictive values for LM-CAD [maximum 15% for a combination of ST-segment depression (STD) in ≥ 5 leads and ECG-EST duration <360 s]. The negative predictive value, however, was very high for some combined ECG-EST variables. Very low risk of LM disease (≤2.5%) was particularly shown in patients with peak heart rate (HR) ≥ 75% of maximal predicted HR for age and STD < 2 mm (prevalence 63.1%; risk 2.2%) and peak HR ≥85% of maximal predicted HR for age and maximal STD < 2 mm (prevalence 46.2%; risk 2.5%).
Conclusions:
Among patients with angina chest pain suspected of obstructive CAD, ECG-EST results can reliably identify those at very low risk of LM disease at coronary angiography.
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