Chest
Exercise and the HeartAre the American College of Cardiology/American Heart Association Guidelines for Exercise Testing for Suspected Coronary Artery Disease Correct?
Section snippets
Patient Population
We screened all inpatients and outpatients referred by primary-care physicians and cardiologists to the stress laboratory for their first exercise test at West Virginia University Hospital between 1981 and 1998. First exercise tests included exercise ECG, nuclear, or echocardiographic studies. We included only symptomatic patients referred with the expressed purpose of evaluating the presence of coronary disease. We considered both the entire population of patients (unselected group) and the
Patient Population
Table 1 lists the clinical and exercise ECG characteristics of the angiography and unselected groups. The angiography group is compared to the patients who did not undergo angiography. Angiography patients had 2.5 times the frequency of positive exercise ECGs, and had a lower proportion of low pretest probability patients.
Exercise Test Accuracy
Overall, sensitivity and specificity in the 872 angiography patients were 42% (149 of 354) and 80% (413 of 518), respectively. Positive and negative predictive values were 59%
Discussion
The recommendations for exercise testing within pretest probability groups presented by the ACC/AHA consensus group were based principally on the added or incremental value. The ROC curve area data on Table 3 support these assignments. However, the predictive value data tell another story. If the intermediate-probability patient undergoes exercise testing, a negative test result on average carries a 28% chance of being falsely negative. While this probability of being wrong will vary depending
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Appropriate use criteria: Lessons from Japan
2014, JACC: Cardiovascular InterventionsAn investigation of dentists' and dental students' estimates of diagnostic probabilities
2010, Journal of the American Dental AssociationCitation Excerpt :These comments expressing frustration with the challenge of making precise estimates of diagnostic probability or expressing doubt about the value of using scientific data to make diagnostic estimates were three times as likely to come from faculty members than from students (31 versus 9 percent, P < .001). The results of this study confirmed our three hypotheses that were based on similar studies in medicine5,6,12–16,18–26: we observed a wide range of diagnostic probability estimates;
Evaluation of pretest and exercise test scores to assess all-cause mortality in unselected patients presenting for exercise testing with symptoms of suspected coronary artery disease
2003, Journal of the American College of CardiologyCitation Excerpt :For low pretest probability patients, exercise testing will most often confirm what is already appreciated from the clinical assessment and will sometimes raise a question for further testing (imaging). In other words, if a stress test is considered for low probability patients, ExECG is the appropriate first choice given its strong negative predictive value (11). For high pretest probability patients, only a minority will be reclassified as low risk, so in the majority, the exercise test will confirm what is already appreciated from the clinical evaluation.
Development and validation of a simple exercise test score for use in women with symptoms of suspected coronary artery disease
2002, American Heart JournalCitation Excerpt :According to Figure 4, women will be categorized by pretest probability as follows: low 60%, intermediate 25%, and high 15%. Prior work from our laboratory indicates that as pretest probability increases, negative predictive value for exercise testing decreases.15 In fact, those in the high pretest probability group have very low negative predictive value and little chance of being reduced to a low posttest probability group by a low exercise score (Figure 4, sector 7).
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