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Diagnostic evaluation of the patient with coronary artery disease
1Department of Cardiology, Cleveland Clinic Foundation, OH 44195.
Insights
Diagnosing coronary artery disease involves balancing test accuracy, cost, and accessibility. While patient history is crucial, noninvasive tests like exercise ECG, echocardiography, and radionuclide studies offer different strengths for effective patient evaluation.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Clinical Medicine
Background:
- Evaluating patients with suspected coronary artery disease presents clinical challenges.
- Clinicians must consider sensitivity, accuracy, cost, and accessibility when selecting diagnostic studies.
- Current practice environments exert conflicting pressures on diagnostic decision-making.
Purpose of the Study:
- To review and compare noninvasive diagnostic techniques for coronary artery disease.
- To highlight the strengths and shortcomings of commonly employed methods.
- To inform rational diagnostic planning for patients with potential coronary artery disease.
Main Methods:
- Comparative review of noninvasive diagnostic techniques.
- Analysis of sensitivity, specificity, cost, and accessibility.
- Consideration of patient-specific factors influencing test selection.
Main Results:
- Patient history remains a cornerstone for diagnosis.
- Exercise electrocardiography (ECG) is less sensitive/specific than exercise echocardiography or radionuclide studies but is cost-effective and accessible.
- New exercise ECG interpretation criteria may enhance diagnostic accuracy.
- Test predictive value is higher in populations with higher disease prevalence (e.g., those with risk factors).
Conclusions:
- Rational diagnostic plans can be developed using existing information and experience.
- Patients unable to exercise or with confounding conditions may require alternative diagnostic techniques.
- The choice of diagnostic study should be tailored to individual patient characteristics and clinical context.
Background:
Evaluation of patients with possible coronary artery disease is a challenge to clinicians who face conflicting pressures in the current practice environment. Sensitivity, accuracy, cost, and access have become considerations in the appropriate selection of diagnostic studies.
Objective:
To review and compare the strengths and shortcomings of commonly employed noninvasive techniques for diagnosing coronary artery disease.
Discussion:
The patient's history is still key in establishing a diagnosis. Exercise electrocardiography (ECG) is not as sensitive or specific as exercise echocardiography or radionuclide studies, but it is relatively inexpensive and accessible. Further, new criteria for interpreting the results of exercise ECG may improve its diagnostic accuracy. The predictive value of any test increases in populations where the prevalence of disease is higher, as in patients with known risk factors for coronary artery disease. Patients who cannot exercise or who have concomitant conditions that obscure the results of exercise ECG are candidates for other diagnostic techniques.
Conclusion:
Rational diagnostic plans for evaluating patients who may have coronary disease can be developed on the basis of existing information and reported experience.