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Gurunathan S, Shanmuganathan M, Chopra A, Pradhan J, Aboud L, Hampson R, Yakupoglu HY, Bioh G, Banfield A, Gage H, Khattar R, Senior R. Comparative effectiveness of exercise electrocardiography versus exercise echocardiography in women presenting with suspected coronary artery disease: a randomized study. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead053. [PMID: 37305342 PMCID: PMC10253116 DOI: 10.1093/ehjopen/oead053] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/28/2023] [Accepted: 05/03/2023] [Indexed: 06/13/2023]
Abstract
Aims There is a paucity of randomized diagnostic studies in women with suspected coronary artery disease (CAD). This study sought to assess the relative value of exercise stress echocardiography (ESE) compared with exercise electrocardiography (Ex-ECG) in women with CAD. Methods and results Accordingly, 416 women with no prior CAD and intermediate probability of CAD (mean pre-test probability 41%), were randomized to undergo either Ex-ECG or ESE. The primary endpoints were the positive predictive value (PPV) for the detection of significant CAD and downstream resource utilization. The PPV of ESE and Ex-ECG were 33% and 30% (P = 0.87), respectively for the detection of CAD. There were similar clinic visits (36 vs. 29, P = 0.44) and emergency visits with chest pain (28 vs. 25, P = 0.55) in the Ex-ECG and ESE arms, respectively. At 2.9 years, cardiac events were 6 Ex-ECG vs. 3 ESE, P = 0.31. Although initial diagnosis costs were higher for ESE, more women underwent further CAD testing in the Ex-ECG arm compared to the ESE arm (37 vs. 17, P = 0.003). Overall, there was higher downstream resource utilization (hospital attendances and investigations) in the Ex-ECG arm (P = 0.002). Using National Health Service tariffs 2020/21 (British pounds) the cumulative diagnostic costs were 7.4% lower for Ex-ECG compared with ESE, but this finding is sensitive to the cost differential between ESE and Ex-ECG. Conclusion In intermediate-risk women who are able to exercise, Ex-ECG had similar efficacy to an ESE strategy, with higher resource utilization whilst providing cost savings.
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Affiliation(s)
- Sothinathan Gurunathan
- Department of Cardiology, Northwick Park Hospital, Harrow, UK
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College, London SW3 6LY, UK
| | | | - Ankur Chopra
- Department of Cardiology, Northwick Park Hospital, Harrow, UK
| | - Jiwan Pradhan
- Department of Cardiology, Northwick Park Hospital, Harrow, UK
| | - Lily Aboud
- Department of Cardiology, Northwick Park Hospital, Harrow, UK
| | | | - Haci Yakup Yakupoglu
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Gabriel Bioh
- Department of Cardiology, Northwick Park Hospital, Harrow, UK
| | - Ann Banfield
- Department of Cardiology, Northwick Park Hospital, Harrow, UK
| | - Heather Gage
- Department of Health Economics, University of Surrey, Guildford, UK
| | - Raj Khattar
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College, London SW3 6LY, UK
| | - Roxy Senior
- Corresponding author. Tel: +44 207 351 8604,
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Choi SY, Sung J, Park HE, Han D, Chang HJ. Combined effects of exercise capacity and coronary atherosclerotic burden on all-cause mortality in asymptomatic Koreans. Atherosclerosis 2016; 251:396-403. [PMID: 27264507 DOI: 10.1016/j.atherosclerosis.2016.05.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 04/28/2016] [Accepted: 05/25/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Both exercise capacity and coronary artery calcium score (CACS) are important prognostic factors in cardiovascular outcome. Yet, whether there is a significant interaction between these two factors in influencing clinical outcome is still uncertain. This study investigated the combined effects of exercise capacity and CACS on all-cause mortality in an asymptomatic population. METHODS From multicenter registry of health screening, a retrospective cohort of 25,972 asymptomatic subjects, who underwent both CACS and treadmill exercise test, was included in the final dataset for analysis. Outcome was defined as all-cause mortality, which was obtained from national mortality registry. RESULTS The mean age of study subjects was 53.7 ± 7.7 years and 81.5% of them were males. Median follow-up duration was 5.5 (IQR 3.6-7.5) years and 226 (0.9%) cases of all-cause mortality occurred. In multivariate Cox's proportional hazard model with interaction term, exercise capacity ≥10 METs (HR 0.684, 95% CI 0.483-0.971) and CACS ≥400 (HR 3.328, 95% CI 1.850-5.988) were significant predictors of all-cause mortality. In patients with higher exercise capacity, the effect of high CACS on all-cause mortality was significantly smaller than in those with lower exercise capacity. The HR for all-cause mortality of CACS ≥400, in those with lower exercise capacity, is estimated to be about three times of that in those with higher exercise capacity (HR 3.328 in <10 METs vs. 1.108 in ≥10 METs, p for interaction = 0.024) after adjustment for age, gender, fasting glucose, creatinine, alanine transaminase and albumin. CONCLUSIONS The effect of high CACS on all-cause mortality is lessened by good exercise capacity in the asymptomatic population. Good physical fitness may reduce the adverse effect of high coronary atherosclerotic burden.
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Affiliation(s)
- Su-Yeon Choi
- Division of Cardiology, Seoul National University Hospital, Healthcare System Gangnam Center, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Jidong Sung
- Division of Cardiology, Sungkyunkwan University School of Medicine, Heart Stroke & Vascular Institute, Samsung Medical Center, Seoul, Republic of Korea.
| | - Hyo Eun Park
- Division of Cardiology, Seoul National University Hospital, Healthcare System Gangnam Center, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Donghee Han
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Hyuk-Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Shaw LJ, Mieres JH, Hendel RH, Boden WE, Gulati M, Veledar E, Hachamovitch R, Arrighi JA, Bairey Merz CN, Gibbons RJ, Wenger NK, Heller GV. Comparative Effectiveness of Exercise Electrocardiography With or Without Myocardial Perfusion Single Photon Emission Computed Tomography in Women With Suspected Coronary Artery Disease. Circulation 2011; 124:1239-49. [DOI: 10.1161/circulationaha.111.029660] [Citation(s) in RCA: 207] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
There is a paucity of randomized trials regarding diagnostic testing in women with suspected coronary artery disease (CAD). It remains unclear whether the addition of myocardial perfusion imaging (MPI) to the standard ECG exercise treadmill test (ETT) provides incremental information to improve clinical decision making in women with suspected CAD.
Methods and Results—
We randomized symptomatic women with suspected CAD, an interpretable ECG, and ≥5 metabolic equivalents on the Duke Activity Status Index to 1 of 2 diagnostic strategies: ETT or exercise MPI. The primary end point was 2-year incidence of major adverse cardiac events, defined as CAD death or hospitalization for an acute coronary syndrome or heart failure. A total of 824 women were randomized to ETT or exercise MPI. For women randomized to ETT, ECG results were normal in 64%, indeterminate in 16%, and abnormal in 20%. By comparison, the exercise MPI results were normal in 91%, mildly abnormal in 3%, and moderate to severely abnormal in 6%. At 2 years, there was no difference in major adverse cardiac events (98.0% for ETT and 97.7% for MPI;
P
=0.59). Compared with ETT, index testing costs were higher for exercise MPI (
P
<0.001), whereas downstream procedural costs were slightly lower (
P
=0.0008). Overall, the cumulative diagnostic cost savings was 48% for ETT compared with exercise MPI (
P
<0.001).
Conclusions—
In low-risk, exercising women, a diagnostic strategy that uses ETT versus exercise MPI yields similar 2-year posttest outcomes while providing significant diagnostic cost savings. The ETT with selective follow-up testing should be considered as the initial diagnostic strategy in symptomatic women with suspected CAD.
Clinical Trial Registration—
http://www.clinicaltrials.gov
. Unique identifier: NCT00282711.
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Affiliation(s)
- Leslee J. Shaw
- From Emory University, Atlanta, GA (L.J.S., E.V., N.K.W.); North Shore–Long Island Jewish Hospital, Manhasset, NY (J.H.M.); University of Miami, Miami, FL (R.H.H.); University of Buffalo, Buffalo, NY (W.E.B.); Ohio State University, Columbus (M.G.); Cleveland Clinic Foundation, Cleveland, OH (R.H.); Brown University, Providence, RI (J.A.A.); Cedars-Sinai Heart Institute, Los Angeles, CA (C.N.B.M.); Mayo Clinic, Rochester, MN (R.J.G.); and Hartford Hospital, Hartford, CT (G.V.H.)
| | - Jennifer H. Mieres
- From Emory University, Atlanta, GA (L.J.S., E.V., N.K.W.); North Shore–Long Island Jewish Hospital, Manhasset, NY (J.H.M.); University of Miami, Miami, FL (R.H.H.); University of Buffalo, Buffalo, NY (W.E.B.); Ohio State University, Columbus (M.G.); Cleveland Clinic Foundation, Cleveland, OH (R.H.); Brown University, Providence, RI (J.A.A.); Cedars-Sinai Heart Institute, Los Angeles, CA (C.N.B.M.); Mayo Clinic, Rochester, MN (R.J.G.); and Hartford Hospital, Hartford, CT (G.V.H.)
| | - Robert H. Hendel
- From Emory University, Atlanta, GA (L.J.S., E.V., N.K.W.); North Shore–Long Island Jewish Hospital, Manhasset, NY (J.H.M.); University of Miami, Miami, FL (R.H.H.); University of Buffalo, Buffalo, NY (W.E.B.); Ohio State University, Columbus (M.G.); Cleveland Clinic Foundation, Cleveland, OH (R.H.); Brown University, Providence, RI (J.A.A.); Cedars-Sinai Heart Institute, Los Angeles, CA (C.N.B.M.); Mayo Clinic, Rochester, MN (R.J.G.); and Hartford Hospital, Hartford, CT (G.V.H.)
| | - William E. Boden
- From Emory University, Atlanta, GA (L.J.S., E.V., N.K.W.); North Shore–Long Island Jewish Hospital, Manhasset, NY (J.H.M.); University of Miami, Miami, FL (R.H.H.); University of Buffalo, Buffalo, NY (W.E.B.); Ohio State University, Columbus (M.G.); Cleveland Clinic Foundation, Cleveland, OH (R.H.); Brown University, Providence, RI (J.A.A.); Cedars-Sinai Heart Institute, Los Angeles, CA (C.N.B.M.); Mayo Clinic, Rochester, MN (R.J.G.); and Hartford Hospital, Hartford, CT (G.V.H.)
| | - Martha Gulati
- From Emory University, Atlanta, GA (L.J.S., E.V., N.K.W.); North Shore–Long Island Jewish Hospital, Manhasset, NY (J.H.M.); University of Miami, Miami, FL (R.H.H.); University of Buffalo, Buffalo, NY (W.E.B.); Ohio State University, Columbus (M.G.); Cleveland Clinic Foundation, Cleveland, OH (R.H.); Brown University, Providence, RI (J.A.A.); Cedars-Sinai Heart Institute, Los Angeles, CA (C.N.B.M.); Mayo Clinic, Rochester, MN (R.J.G.); and Hartford Hospital, Hartford, CT (G.V.H.)
| | - Emir Veledar
- From Emory University, Atlanta, GA (L.J.S., E.V., N.K.W.); North Shore–Long Island Jewish Hospital, Manhasset, NY (J.H.M.); University of Miami, Miami, FL (R.H.H.); University of Buffalo, Buffalo, NY (W.E.B.); Ohio State University, Columbus (M.G.); Cleveland Clinic Foundation, Cleveland, OH (R.H.); Brown University, Providence, RI (J.A.A.); Cedars-Sinai Heart Institute, Los Angeles, CA (C.N.B.M.); Mayo Clinic, Rochester, MN (R.J.G.); and Hartford Hospital, Hartford, CT (G.V.H.)
| | - Rory Hachamovitch
- From Emory University, Atlanta, GA (L.J.S., E.V., N.K.W.); North Shore–Long Island Jewish Hospital, Manhasset, NY (J.H.M.); University of Miami, Miami, FL (R.H.H.); University of Buffalo, Buffalo, NY (W.E.B.); Ohio State University, Columbus (M.G.); Cleveland Clinic Foundation, Cleveland, OH (R.H.); Brown University, Providence, RI (J.A.A.); Cedars-Sinai Heart Institute, Los Angeles, CA (C.N.B.M.); Mayo Clinic, Rochester, MN (R.J.G.); and Hartford Hospital, Hartford, CT (G.V.H.)
| | - James A. Arrighi
- From Emory University, Atlanta, GA (L.J.S., E.V., N.K.W.); North Shore–Long Island Jewish Hospital, Manhasset, NY (J.H.M.); University of Miami, Miami, FL (R.H.H.); University of Buffalo, Buffalo, NY (W.E.B.); Ohio State University, Columbus (M.G.); Cleveland Clinic Foundation, Cleveland, OH (R.H.); Brown University, Providence, RI (J.A.A.); Cedars-Sinai Heart Institute, Los Angeles, CA (C.N.B.M.); Mayo Clinic, Rochester, MN (R.J.G.); and Hartford Hospital, Hartford, CT (G.V.H.)
| | - C. Noel Bairey Merz
- From Emory University, Atlanta, GA (L.J.S., E.V., N.K.W.); North Shore–Long Island Jewish Hospital, Manhasset, NY (J.H.M.); University of Miami, Miami, FL (R.H.H.); University of Buffalo, Buffalo, NY (W.E.B.); Ohio State University, Columbus (M.G.); Cleveland Clinic Foundation, Cleveland, OH (R.H.); Brown University, Providence, RI (J.A.A.); Cedars-Sinai Heart Institute, Los Angeles, CA (C.N.B.M.); Mayo Clinic, Rochester, MN (R.J.G.); and Hartford Hospital, Hartford, CT (G.V.H.)
| | - Raymond J. Gibbons
- From Emory University, Atlanta, GA (L.J.S., E.V., N.K.W.); North Shore–Long Island Jewish Hospital, Manhasset, NY (J.H.M.); University of Miami, Miami, FL (R.H.H.); University of Buffalo, Buffalo, NY (W.E.B.); Ohio State University, Columbus (M.G.); Cleveland Clinic Foundation, Cleveland, OH (R.H.); Brown University, Providence, RI (J.A.A.); Cedars-Sinai Heart Institute, Los Angeles, CA (C.N.B.M.); Mayo Clinic, Rochester, MN (R.J.G.); and Hartford Hospital, Hartford, CT (G.V.H.)
| | - Nanette K. Wenger
- From Emory University, Atlanta, GA (L.J.S., E.V., N.K.W.); North Shore–Long Island Jewish Hospital, Manhasset, NY (J.H.M.); University of Miami, Miami, FL (R.H.H.); University of Buffalo, Buffalo, NY (W.E.B.); Ohio State University, Columbus (M.G.); Cleveland Clinic Foundation, Cleveland, OH (R.H.); Brown University, Providence, RI (J.A.A.); Cedars-Sinai Heart Institute, Los Angeles, CA (C.N.B.M.); Mayo Clinic, Rochester, MN (R.J.G.); and Hartford Hospital, Hartford, CT (G.V.H.)
| | - Gary V. Heller
- From Emory University, Atlanta, GA (L.J.S., E.V., N.K.W.); North Shore–Long Island Jewish Hospital, Manhasset, NY (J.H.M.); University of Miami, Miami, FL (R.H.H.); University of Buffalo, Buffalo, NY (W.E.B.); Ohio State University, Columbus (M.G.); Cleveland Clinic Foundation, Cleveland, OH (R.H.); Brown University, Providence, RI (J.A.A.); Cedars-Sinai Heart Institute, Los Angeles, CA (C.N.B.M.); Mayo Clinic, Rochester, MN (R.J.G.); and Hartford Hospital, Hartford, CT (G.V.H.)
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