Incremental prognostic power of clinical history, exercise electrocardiography and myocardial perfusion scintigraphy in suspected coronary artery disease

doi:10.1016/0002-9149(87)90798-3

The American Journal of Cardiology

Volume 59, Issue 4, 1 February 1987, Pages 270-277

https://doi.org/10.1016/0002-9149(87)90798-3 Get rights and content

Abstract

The incremental ability of a clinical history, exercise electrocardiography (ECG) and myocardial perfusion scintigraphy to identify coronary events in the year after testing was assessed in 1,659 patients with symptoms suggestive of coronary artery disease (CAD), 74 of whom suffered a coronary event in the year after testing. Prognostic power was quantified in terms of the area under receiver operating characteristic curves derived from logistic regression. In 1,451 patients with normal rest ECG findings, a clinical history alone provided the most prognostic power (area = 72%). This improved significantly (by 5%) only when both tests were analyzed. In contrast, clinical history had significantly less prognostic power in the 208 patients with abnormal rest ECG findings (area = 58%), but each test then provided a significant incremental improvement in these patients (by 14% for each). A strategic model was thereby developed for prognostic assessment that recognizes the incremental power of these tests in specific patient groups as well as their overall accuracy and monetary cost. This strategy stratified individual patient risk for subsequent coronary events over a full order of magnitude (from 2 to 22%) at a 64% reduction in the cost of testing compared to performing both stress tests in all patients.

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First, early research demonstrated that stress MPI had inherently greater sensitivity and specificity for the detection of angiographically significant CAD compared with exercise ECG. Subsequent work demonstrated that stress MPI provided incremental prognostic information when first assessing risk according to more readily available clinical information, such as CAD risk factors and the results of exercise ECG.2–4 Moreover, whereas exercise ECG is an imprecise measure of the magnitude of inducible myocardial ischemia, stress MPI can precisely quantify the magnitude of ischemia according to its regional extent (eg, the number and location of reversible myocardial perfusion defects) and the severity of perfusion defects.
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^☆: This study was funded in part by Specialized Center of Research (SCOR) Grant (HL-17651) and by Training Grant 2T32HL07380 from the National Heart, Lung, and Blood Institute, National Institutes of Heath, Bethesda, Maryland.

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Incremental prognostic power of clinical history, exercise electrocardiography and myocardial perfusion scintigraphy in suspected coronary artery disease☆

Abstract

Am J Cardiol

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