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Original Research: Robert J. Newman, Mark Darrow, Doyle M. Cummings, Valerie King, Lauren Whetstone, Suzanne Kelly, and Eric Jalonen Predictive Value of Exercise Stress Testing in a Family Medicine Population J Am Board Fam Med 2008; 21: 531-538 [Abstract] [Full text] [PDF]

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Previous studies of predictive values

Markku PT Sumanen, Kari J. Mattila   (24 November 2008)

EST: screening vs. triage

Peter G. Teichman   (12 November 2008)

Previous studies of predictive values 24 November 2008
Markku PT Sumanen, MD, PhD Medical School, University of Tampere, Finland, Kari J. Mattila Send response to journal: Re: Previous studies of predictive values markku.sumanen{at}uta.fi Markku PT Sumanen, et al.	We read with great interest the article concerning the predictive values of exercise stress testing in a family medicine population. The results confirm the findings we have reported in our studies a few years ago. In our studies the predictive negative value of the test was 98% both among working-age population and among older patients. Therefore, we would like to point out that the authors’ statement to be the only ones to study predictive values of EST for patient-oriented outcomes in family medicine is not entirely correct. Here you can see the references to our original articles. Sumanen M, Jussila M, Mattila K. Exercise treadmill test may predict clinical outcome among working-aged patients suspected of coronary heart disease in general practice. Scandinavian Journal of Primary Health Care. 2005;23(1):47-51. Sumanen M, Mattila K. A negative finding in an exercise test is reliable among elderly people: a follow-up study. Gerontology. 2007;53(3):159-64. Yours sincerely, Markku Sumanen MD, PhD Senior lecturer of General Practice University of Tampere, Medical School Finland Kari Mattila MD, PhD, Professor of General Practice University of Tampere, Medical School Finland
EST: screening vs. triage 12 November 2008
Peter G. Teichman, Family Medicine Physician FV Hospital, HCM City, VIETNAM Send response to journal: Re: EST: screening vs. triage keqfap{at}yahoo.co.nz Peter G. Teichman	This study adds perspective to the role of exercise stress testing (EST) in triaging primary care patients with cardiac symptoms or risk factors. It also belies its first sentence, "Exercise stress testing (EST) is a screening test for coronary artery disease." Only 2.3% of the studied patients presented for screening. Another 31% of patients received EST for no listed indication or for pre-exercise evaluation. Though the retrospective study design limits our insight, it is more likely than not that these additional patients had cardiac symptoms or risk factors. In this study, all patients with positive cardiac outcomes, regardless of EST results, had at least one risk factor. All asymptomatic patients had a very low or low pretest probability of coronary artery disease, with associated high NPVs of EST. Unless triage of at risk (by symptoms or risk factors) primary care patients is conflated with screening (attempts to detect treatable presymptomatic disease), this combination of findings affirms both the effectiveness of EST in triage and the lack of effectiveness of EST in screening.