Exercise echocardiography is an accurate and cost-efficient technique for detection of coronary artery disease in women

Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195, USA.

OBJECTIVES. This study compared the accuracy and cost implications of using exercise echocardiography and exercise electrocardiography for detection of coronary artery disease in women. BACKGROUND. The specificity of exercise electrocardiography in women is lower than in men. Exercise echocardiography accurately identifies coronary artery disease in women, but its utility in place of exercise electrocardiography is unclear. METHODS. One hundred sixty-one women without a previous Q wave infarction underwent exercise echocardiography and coronary angiography. Positive findings were a new or worsening wall motion abnormality on the exercise echocardiogram and ST segment depression > 0.1 mV at 0.08 s after the J point on the exercise electrocardiogram (ECG). RESULTS. Coronary artery stenosis > 50% diameter narrowing was present in 59 patients; the sensitivity (mean +/- SD) of exercise echocardiography was 80 +/- 3%. In 48 patients with an interpretable ECG, the sensitivity of exercise echocardiography was 81 +/- 4%, and that of the exercise ECG was 77 +/- 3% (p = 0.50). In 102 patients without coronary artery disease, the overall specificity of exercise echocardiography was 81 +/- 4%. In 70 patients with an interpretable ECG, the specificity of exercise echocardiography (80 +/- 3%) exceeded that of the exercise ECG (56 +/- 4%, p < 0.0004). The accuracy of exercise echocardiography was also greater than exercise electrocardiography (81 +/- 5% vs. 64 +/- 6%, p < 0.005). Exercise echocardiography stratified significantly more patients of intermediate (20% to 80%) pretest disease probability into the high (> 80%) or low (< 20%) posttest probability group. In women without a previous exercise ECG, the specificity of exercise echocardiography continued to exceed that of exercise electrocardiography (80 +/- 3% vs. 64 +/- 3%, p = 0.05). Exercise echocardiography had the best balance between accuracy and cost for the diagnosis of coronary artery disease in women. CONCLUSIONS. Exercise echocardiography is more specific than exercise electrocardiography for diagnosis of coronary artery disease in women and is a cost-effective approach to the diagnosis of coronary artery disease because of the avoidance of inappropriate angiography.

This article has been cited by other articles:

				R. S. Wright, J. L. Anderson, C. D. Adams, C. R. Bridges, D. E. Casey Jr, S. M. Ettinger, F. M. Fesmire, T. G. Ganiats, H. Jneid, A. M. Lincoff, et al. 2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines J. Am. Coll. Cardiol., May 10, 2011; 57(19): e215 - e367. [Full Text] [PDF]

				J. L. Anderson, C. D. Adams, E. M. Antman, C. R. Bridges, R. M. Califf, D. E. Casey Jr, W. E. Chavey II, F. M. Fesmire, J. S. Hochman, T. N. Levin, et al. 2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Circulation, May 10, 2011; 123(18): e426 - e579. [Full Text] [PDF]

				L. Cortigiani and E. Picano Chapter 13 Stress echocardiography The EAE Textbook of Echocardiography, March 1, 2011; 1(1): med-9780199599639-chapter - med-9780199599639-chapter. [Abstract] [Full Text]

				R. C. Cury, T. Techasith, G. Feuchtner, and G. Dabus Cardiovascular Disease and Stroke in Women: Role of Radiology Am. J. Roentgenol., February 1, 2011; 196(2): 265 - 273. [Abstract] [Full Text] [PDF]

				P. Kohli and M. Gulati Exercise Stress Testing in Women: Going Back to the Basics Circulation, December 14, 2010; 122(24): 2570 - 2580. [Full Text] [PDF]

				F. A. Flachskampf and W. G. Daniel Cardiac imaging in the patient with chest pain: echocardiography Heart, July 1, 2010; 96(13): 1063 - 1072. [Full Text] [PDF]

				R. Gebker, C. Jahnke, T. Hucko, R. Manka, J. G. Mirelis, A. Hamdan, B. Schnackenburg, E. Fleck, and I. Paetsch Dobutamine stress magnetic resonance imaging for the detection of coronary artery disease in women Heart, April 1, 2010; 96(8): 616 - 620. [Abstract] [Full Text] [PDF]

				A. Bouzas-Mosquera, J. Peteiro, N. Alvarez-Garcia, F. J. Broullon, V. X. Mosquera, L. Garcia-Bueno, L. Ferro, and A. Castro-Beiras Prediction of Mortality and Major Cardiac Events by Exercise Echocardiography in Patients With Normal Exercise Electrocardiographic Testing J. Am. Coll. Cardiol., May 26, 2009; 53(21): 1981 - 1990. [Abstract] [Full Text] [PDF]

				R. Sicari, P. Nihoyannopoulos, A. Evangelista, J. Kasprzak, P. Lancellotti, D. Poldermans, J.-U. Voigt, J. L. Zamorano, and on behalf of the European Association of Echocardi Stress echocardiography expert consensus statement: European Association of Echocardiography (EAE) (a registered branch of the ESC) Eur Heart J Cardiovasc Imaging, July 1, 2008; 9(4): 415 - 437. [Abstract] [Full Text] [PDF]

				V. Stangl, V. Witzel, G. Baumann, and K. Stangl Current diagnostic concepts to detect coronary artery disease in women Eur. Heart J., March 2, 2008; 29(6): 707 - 717. [Abstract] [Full Text] [PDF]

				J. L. Anderson, C. D. Adams, E. M. Antman, C. R. Bridges, R. M. Califf, D. E. Casey Jr, W. E. Chavey II, F. M. Fesmire, J. S. Hochman, T. N. Levin, et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) Developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine J. Am. Coll. Cardiol., August 14, 2007; 50(7): e1 - e157. [Full Text] [PDF]

				J. L. Anderson, C. D. Adams, E. M. Antman, C. R. Bridges, R. M. Califf, D. E. Casey Jr, W. E. Chavey II, F. M. Fesmire, J. S. Hochman, T. N. Levin, et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction) Developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine J. Am. Coll. Cardiol., August 14, 2007; 50(7): 652 - 726. [Full Text] [PDF]

				L. J. Shaw, T. H. Marwick, D. S. Berman, S. Sawada, G. V. Heller, C. Vasey, and D. D. Miller Incremental cost-effectiveness of exercise echocardiography vs. SPECT imaging for the evaluation of stable chest pain Eur. Heart J., October 2, 2006; 27(20): 2448 - 2458. [Abstract] [Full Text] [PDF]

				W. F. Armstrong and W. A. Zoghbi Stress Echocardiography: Current Methodology and Clinical Applications J. Am. Coll. Cardiol., June 7, 2005; 45(11): 1739 - 1747. [Abstract] [Full Text] [PDF]

				L. J. Shaw, C. Vasey, S. Sawada, C. Rimmerman, and T. H. Marwick Impact of gender on risk stratification by exercise and dobutamine stress echocardiography: long-term mortality in 4234 women and 6898 men Eur. Heart J., March 1, 2005; 26(5): 447 - 456. [Abstract] [Full Text] [PDF]

				R. Bigi and L. Cortigiani Stress testing in women: sexual discrimination or equal opportunity? Eur. Heart J., March 1, 2005; 26(5): 423 - 425. [Full Text] [PDF]

				J. H. Mieres, L. J. Shaw, A. Arai, M. J. Budoff, S. D. Flamm, W. G. Hundley, T. H. Marwick, L. Mosca, A. R. Patel, M. A. Quinones, et al. Role of Noninvasive Testing in the Clinical Evaluation of Women With Suspected Coronary Artery Disease: Consensus Statement From the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association Circulation, February 8, 2005; 111(5): 682 - 696. [Abstract] [Full Text] [PDF]

				D. J. Pennell, U. P. Sechtem, C. B. Higgins, W. J. Manning, G. M. Pohost, F. E. Rademakers, A. C. van Rossum, L. J. Shaw, and E. K. Yucel Clinical indications for cardiovascular magnetic resonance (CMR): Consensus Panel report Eur. Heart J., November 1, 2004; 25(21): 1940 - 1965. [Full Text] [PDF]

				K. Nasir, R. F. Redberg, M. J. Budoff, E. Hui, W. S. Post, and R. S. Blumenthal Utility of Stress Testing and Coronary Calcification Measurement for Detection of Coronary Artery Disease in Women Arch Intern Med, August 9, 2004; 164(15): 1610 - 1620. [Abstract] [Full Text] [PDF]

				L. J. Shaw, J. F. Lewis, M. A. Hlatky, W. A. Hsueh, S. F. Kelsey, R. Klein, T. A. Manolio, A. R. Sharrett, R. P. Tracy, and Endorsed by the American College of Cardiology Fou Women's Ischemic Syndrome Evaluation: Current Status and Future Research Directions: Report of the National Heart, Lung and Blood Institute Workshop: October 2-4, 2002: Section 5: Gender-Related Risk Factors for Ischemic Heart Disease Circulation, February 17, 2004; 109(6): e56 - e58. [Full Text] [PDF]

				M. D. Cheitlin, W. F. Armstrong, G. P. Aurigemma, G. A. Beller, F. Z. Bierman, J. L. Davis, P. S. Douglas, D. P. Faxon, L. D. Gillam, T. R. Kimball, et al. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article: a report of the American college of cardiology/American heart association task force on practice guidelines (ACC/AHA/ASE committee to update the 1997 guidelines for the clinical application of echocardiography) J. Am. Coll. Cardiol., September 3, 2003; 42(5): 954 - 970. [Full Text] [PDF]

				M. D. Cheitlin, W. F. Armstrong, G. P. Aurigemma, G. A. Beller, F. Z. Bierman, J. L. Davis, P. S. Douglas, D. P. Faxon, L. D. Gillam, T. R. Kimball, et al. ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography: Summary Article: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography) Circulation, September 2, 2003; 108(9): 1146 - 1162. [Full Text] [PDF]

				T.H. Marwick, L. Shaw, C. Case, C. Vasey, and J.D. Thomas Clinical and economic impact of exercise electrocardiography and exercise echocardiography in clinical practice Eur. Heart J., June 2, 2003; 24(12): 1153 - 1163. [Abstract] [Full Text] [PDF]

				T. H Marwick Stress echocardiography Heart, January 1, 2003; 89(1): 113 - 118. [Full Text] [PDF]

				A. M. Arruda-Olson, E. M. Juracan, D. W. Mahoney, R. B. McCully, V. L. Roger, and P. A. Pellikka Prognostic value of exercise echocardiographyin 5,798 patients: is there a gender difference? J. Am. Coll. Cardiol., February 20, 2002; 39(4): 625 - 631. [Abstract] [Full Text] [PDF]

				N. K Wenger Clinical characteristics of coronary heart disease in women: emphasis on gender differences Cardiovasc Res, February 15, 2002; 53(3): 558 - 567. [Full Text] [PDF]

				J I Davar, E B Roberts, J G Coghlan, T R Evans, and D P Lipkin Prognostic value of stress echocardiography in women with high ({>=}80%) probability of coronary artery disease Postgrad. Med. J., September 1, 2001; 77(911): 573 - 577. [Abstract] [Full Text] [PDF]

				D.R. Holdright The role of pharmacological stress echo for evaluating chest pain in women Eur. Heart J., January 2, 2001; 22(2): 107 - 109. [PDF]

				E. Braunwald, E. M. Antman, J. W. Beasley, R. M. Califf, M. D. Cheitlin, J. S. Hochman, R. H. Jones, D. Kereiakes, J. Kupersmith, T. N. Levin, et al. ACC/AHA guidelines for the management of patients with unstable angina and non-st-segment elevation myocardial infarction: A report of the american college of cardiology/ american heart association task force on practice guidelines (committee on the management of patients with unstable angina) J. Am. Coll. Cardiol., September 1, 2000; 36(3): 970 - 1062. [Full Text] [PDF]

				R. J. Gibbons, K. Chatterjee, J. Daley, J. S. Douglas, S. D. Fihn, J. M. Gardin, M. A. Grunwald, D. Levy, B. W. Lytle, R. A. O'Rourke, et al. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina) J. Am. Coll. Cardiol., June 1, 1999; 33(7): 2092 - 2197. [Full Text] [PDF]

				L. Cortigiani, C. Dodi, E. A. Paolini, D. Bernardi, G. Bruno, and E. Nannini Prognostic value of pharmacological stress echocardiography in women with chest pain and unknown coronary artery disease J. Am. Coll. Cardiol., December 1, 1998; 32(7): 1975 - 1981. [Abstract] [Full Text] [PDF]

				M. S. Lauer, R. Mehta, F. J. Pashkow, P. M. Okin, K. Lee, and T. H. Marwick Association of chronotropic incompetence with echocardiographic ischemia and prognosis J. Am. Coll. Cardiol., November 1, 1998; 32(5): 1280 - 1286. [Abstract] [Full Text] [PDF]

				K. E. Fleischmann, M. G. M. Hunink, K. M. Kuntz, and P. S. Douglas Exercise Echocardiography or Exercise SPECT Imaging?: A Meta-analysis of Diagnostic Test Performance JAMA, September 9, 1998; 280(10): 913 - 920. [Abstract] [Full Text] [PDF]

				L. Mosca, J. E. Manson, S. E. Sutherland, R. D. Langer, T. Manolio, E. Barrett-Connor, and E. Barrett-Connor Cardiovascular Disease in Women : A Statement for Healthcare Professionals From the American Heart Association Circulation, October 7, 1997; 96(7): 2468 - 2482. [Full Text]

				V. L. Roger, P. A. Pellikka, M. R. Bell, C. W.H. Chow, K. R. Bailey, and J. B Seward Sex and Test Verification Bias: Impact on the Diagnostic Value of Exercise Echocardiography Circulation, January 21, 1997; 95(2): 405 - 410. [Abstract] [Full Text]