Accuracy of heart rate-adjusted ST segments in populations with and without posttest referral bias

We compared the accuracy of the ST segment/heart rate (STHR) index and slope to standard criteria (> or =1 mm horizontal/downsloping ST-segment depression at J + 60 msec) in 1358 patients (152 underwent angiography). All exercise tests used the Cornell protocol and computer measurements of maximum ST-segment depression at J + 60 msec. Test accuracy was determined for the entire group with a probability-based method. Thresholds with equal specificity to standard criteria were determined. By using only patients who underwent angiography, neither STHR index nor slope was more accurate than standard criteria (maximum sensitivity: standard criteria, 42%; STHR index, 51%; STHR slope, 40%). However, by using the entire group, both STHR index and slope were more accurate than standard criteria, but only STHR index achieved statistical significance (maximum sensitivity: standard criteria, 31%; STHR index, 60%; STHR slope, 47%). We conclude that heart rate-adjusted ST-segment criteria are more accurate than standard ST-segment criteria. A lack of demonstration of improved accuracy of STHR index and slope only occurs in patients affected by posttest referral bias.