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Research ArticleOriginal Research

Predictive Value of Exercise Stress Testing in a Family Medicine Population

Robert J. Newman, Mark Darrow, Doyle M. Cummings, Valerie King, Lauren Whetstone, Suzanne Kelly and Eric Jalonen
The Journal of the American Board of Family Medicine November 2008, 21 (6) 531-538; DOI: https://doi.org/10.3122/jabfm.2008.06.070257
Robert J. Newman
MD
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Mark Darrow
MD
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Doyle M. Cummings
PharmD
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Valerie King
MD, MPH
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Lauren Whetstone
PhD
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Suzanne Kelly
MPH
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Eric Jalonen
BA
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    Figure 1.

    Summary of exercise stress testing results.

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    Table 1.

    Characteristics of the Exercise Stress Testing Study Population

    Age (years)
        Mean (range)50.0 (24–91)
        SD±10.66
    Sex (%)
        Men52
        Women48
    Race (%)
        African-American52
        White45
        Other3
    Risk Factors (% [n])
        Hypertension59 (201)
        Hypercholesterolemia29 (99)
        Diabetes Mellitus23 (78)
        Smoker, previous or current21 (70)
        Family history of CAD8 (27)
        None reported20 (69)
    • CAD, coronary artery disease.

    • View popup
    Table 2.

    Exercise Stress Testing Outcomes*

    Cardiac Outcomes†
    Treadmill ResultYesNoTotalValueCI
        Positive‡53237
        Negative2300302
        Total7332339
    Sensitivity0.71430.3589–0.9178
    Specificity0.90360.8671–0.9309
    PPV0.13510.0591–0.2797
    NPV0.99340.9762–0.9982
    Positive likelihood ratio7.41104.1800–13.1400
    Negative likelihood ratio0.31600.0980–1.0210
    Probability of disease0.02600.0100–0.0419
    Overall accuracy0.89970.8631–0.9286
    • * Calculations were based on formulas from http://faculty.vassar.edu/lowry/prop1.html. Formulas for confidence intervals from Newcome RG. Two sided confidence intervals for the single proportion; comparison of seven methods. Stat Med 1998;17:857–72.

    • † Cardiac outcomes included myocardial infarction, cardiac catheterization with angioplasty and stenting, coronary artery bypass graft, new diagnosis of coronary artery disease, and cardiac death.

    • ‡ Equivocal results are included as positive tests.

    • View popup
    Table 3.

    Patients with Positive Cardiac Outcomes

    Patient NumberEST ResultCardiac OutcomeTime to OutcomeDescriptive Data
    Age (yr)Race/SexRisk Factors
    74PositiveAcute MI; catheterization; stenting 2 vessels10 months65African-American maleHTN, DM, hypercholesterolemia
    128NegativeAcute MI; catheterization; stenting single vessel2 months51African-American maleHTN, smoker, hypercholesterolemia
    157EquivocalCatheterization; stenting 2 vessels; subsequent CABG5 weeks57African-American maleDM, HTN, Hypercholesterolemia
    176PositiveCatheterization; stenting 2 vessels2 months42White maleFH, CAD, hypercholesterolemia
    230NegativeCatheterization; 3-vessel CAD; CABG29 months49White maleHTN, negative EST (May 2004), positive stress echo (October 2006)
    271EquivocalCatheterization; stenting single vessel5 weeks44White maleSmoker, HTN
    298PositiveCatheterization; 3-vessel CAD; CABG1 week54White maleHTN, DM, hypercholesterolemia
    • EST, exercise stress test; MI, myocardial infarction; HTN, hypertension; DM, diabetes mellitus; CAD, coronary artery disease; CABG, coronary artery bypass graft.

    • View popup
    Table 4.

    Selection of Patients for Exercise Stress Testing in a Primary Care Setting

    ACC/AHA Class
    1. Symptomatic patients—adults with chest pain with intermediate pretest probability of CAD (see Table 5)*I
    2. Generating an exercise prescription
    3. Determining functional capacity
    4. Evaluating antianginal therapy†I
    5. Evaluating patients after MI for risk stratification†I
    6. Establishing severity and prognosis of CAD –Duke Score assessment†I
    7. Evaluating dysrhythmiasII
    8. Asymptomatic patients (limited indications)
        A. Diabetics before starting moderate- to high-intensity exercise and age >35 years; type 2 DM for >10 years; type 1 DM for >15 years; presence of other cardiac risk factors, microvascular complications, or macrovascular complicationsIIA
        B. Men >45 years old, women >55 years old who plan to start a vigorous exercise program; high-risk public safety occupations; high risk for CAD with multiple other CAD risk factorsIIB
    • Modified from refs. 10 and 28.

    • * This is the most common indication.

    • † Some primary care physicians may choose to refer these patients with known CAD for exercise sestamibi study.

    • ACC/AHA, American College of Cardiology/American Heart Association ; CAD, coronary artery disease; MI, myocardial infarction; DM, diabetes mellitus.

    • View popup
    Table 5.

    Pretest Probability of Coronary Artery Disease by Age, Gender, and Symptoms*

    Age (years)GenderTypical Angina PectorisAtypical Chest PainNonanginal Chest PainAsymptomatic
    30–39MenIntermediateIntermediateLowVery low
    WomenIntermediateVery lowVery lowVery low
    40–49MenHighIntermediateIntermediateLow
    WomenIntermediateLowVery lowVery low
    50–59MenHighIntermediateIntermediateLow
    WomenIntermediateIntermediateLowVery Low
    60–69MenHighIntermediateIntermediateLow
    WomenHighIntermediateIntermediateLow
    • Modified from refs. 10 and 28.

    • * High indicates >90%; intermediate, 10% to 90%; low, <10%; very low, <5%. Intermediate pretest probability is an ACC/AHA Class I indication for exercise stress testing.

    • View popup
    Table 6.

    Suggested Exclusion Criteria for Exercise Stress Testing in a Primary Care Setting

    1. Contraindications (see Table 7)
    2. Patients who cannot walk ≥2 flights of stairs or 2 city blocks; refer for adenosine or dobutamine sestamibi study
    3. Patients with resting EKG abnormalities: right or left bundle branch block, ST segment depression at rest; refer for ESS
    4. Women with high pretest probability (see Table 4); refer for stress echocardiography
    5. Men with high pretest probability (see Table 4); refer for ESS
    6. Patients on digoxin; refer for ESS
    7. Patients with Wolf-Parkinson-White Syndrome; refer for ESS
    8. Patients with paced rhythm; refer for ESS
    9. In general, patients with known CAD should undergo ESS, although valuable information can be gained from exercise stress test
    • Modified from refs. 10 and 28.

    • EKG, electrocardiogram; ESS, exercise sestamibi study; CAD, coronary artery disease.

    • View popup
    Table 7.

    Contraindications to Exercise Stress Testing

    Absolute
        Acute myocardial infarction (within 2 days)
        High-risk unstable angina
        Uncontrolled cardiac arrhythmias
        Symptomatic severe aortic stenosis
        Uncontrolled symptomatic heart failure
        Acute pulmonary embolus or pulmonary infarction
        Acute myocarditis or pericarditis
        Acute aortic dissection
    Relative
        Left main coronary stenosis
        Moderate stenotic valvular heart disease
        Electrolyte abnormalities
        Severe arterial hypertension (>200/110)
        Tachyarrhythmias or bradyarrhythmias
        Hypertrophic cardiomyopathy and other forms of outflow tract obstruction
        Mental or physical impairment leading to inability or willingness to exercise adequately
        High-degree atrioventricular block
    • Modified from ref. 10.

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The Journal of the American Board of Family Medicine: 21 (6)
The Journal of the American Board of Family Medicine
Vol. 21, Issue 6
November-December 2008
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Predictive Value of Exercise Stress Testing in a Family Medicine Population
Robert J. Newman, Mark Darrow, Doyle M. Cummings, Valerie King, Lauren Whetstone, Suzanne Kelly, Eric Jalonen
The Journal of the American Board of Family Medicine Nov 2008, 21 (6) 531-538; DOI: 10.3122/jabfm.2008.06.070257

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Predictive Value of Exercise Stress Testing in a Family Medicine Population
Robert J. Newman, Mark Darrow, Doyle M. Cummings, Valerie King, Lauren Whetstone, Suzanne Kelly, Eric Jalonen
The Journal of the American Board of Family Medicine Nov 2008, 21 (6) 531-538; DOI: 10.3122/jabfm.2008.06.070257
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