Published 13 November 2008, doi:10.1136/bmj.a2240
Cite this as: BMJ 2008;337:a2240

Research

Incremental prognostic value of the exercise electrocardiogram in the initial assessment of patients with suspected angina: cohort study

¹ Newham University Hospital, London, ² Barts and The London Queen Mary’s School of Medicine and Dentistry, London, ³ Department of Epidemiology and Public Health, University College London Medical School, London, ⁴ Unit of Academic Primary Health Care, University of Bristol

Objective To determine whether resting and exercise electrocardiograms (ECGs) provide prognostic value that is incremental to that obtained from the clinical history in ambulatory patients with suspected angina attending chest pain clinics.

Design Multicentre cohort study.

Setting Rapid access chest pain clinics of six hospitals in England.

Participants 8176 consecutive patients with suspected angina and no previous diagnosis of coronary artery disease, all of whom had a resting ECG recorded. 4848 patients with a summary exercise ECG result recorded (positive, negative, equivocal for ischaemia) comprised the summary ECG subset of whom 1422 with more detailed exercise ECG data recorded comprised the detailed ECG subset.

Main outcome measure Composite of death due to coronary heart disease or non-fatal acute coronary syndrome during median follow-up of 2.46 years.

Results Receiver operating characteristics curves for the basic clinical assessment model alone and with the results of resting ECGs were superimposed with little difference in the C statistic. With the exercise ECGs the C statistic in the summary ECG subset increased from 0.70 (95% confidence interval 0.68 to 0.73) to 0.74 (0.71 to 0.76) and in the detailed ECG subset from 0.74 (0.70 to 0.79) to 0.78 (0.74 to 0.82). However, risk stratified cumulative probabilities of the primary end point at one year and six years for all three prognostic indices (clinical assessment only; clinical assessment plus resting ECG; clinical assessment plus resting ECG plus exercise ECG) showed only small differences at all time points and at all levels of risk.

Conclusion In ambulatory patients with suspected angina, basic clinical assessment encompasses nearly all the prognostic value of resting ECGs and most of the prognostic value of exercise ECGs. The limited incremental value of these widely applied tests emphasises the need for more effective methods of risk stratification in this group of patients.

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    StumbleUpon    Technorati    What's this?

Relevant Articles

Cost effective investigation of suspected angina

S Richard Underwood
BMJ 2008 337: a3097. [Extract] [Full Text]

Sensitivity and specificity of exercise ECG in heart disease

Kevin Barraclough
BMJ 2008 337: a3098. [Extract] [Full Text]

Electrocardiography in suspected angina

Beth Abramson
BMJ 2008 337: a2340. [Extract] [Full Text]

Predicting prognosis in stable angina—results from the Euro heart survey of stable angina: prospective observational study

Caroline A Daly, Bianca De Stavola, Jose L Lopez Sendon, Luigi Tavazzi, Eric Boersma, Felicity Clemens, Nicholas Danchin, Francois Delahaye, Anselm Gitt, Desmond Julian, David Mulcahy, Witold Ruzyllo, Kristian Thygesen, Freek Verheugt, Kim M Fox on behalf of the Euro Heart Survey Investigators
BMJ 2006 332: 262-267. [Abstract] [Full Text] [PDF]

Risk score for predicting death, myocardial infarction, and stroke in patients with stable angina, based on a large randomised trial cohort of patients

Tim C Clayton, Jacobus Lubsen, Stuart J Pocock, Zoltán Vokó, Bridget-Anne Kirwan, Keith A A Fox, Philip A Poole-Wilson on behalf of the ACTION investigators
BMJ 2005 331: 869. [Abstract] [Full Text] [PDF]

This article has been cited by other articles:

• Nieman, K, Galema, T, Weustink, A, Neefjes, L, Moelker, A, Musters, P, de Visser, R, Mollet, N, Boersma, H, de Feijter, P J (2009). Computed tomography versus exercise electrocardiography in patients with stable chest complaints: real-world experiences from a fast-track chest pain clinic. Heart 95: 1669-1675 [Abstract] [Full text]  
• Underwood, S R. (2008). Cost effective investigation of suspected angina. BMJ 337: a3097-a3097 [Full text]  
• Barraclough, K. (2008). Sensitivity and specificity of exercise ECG in heart disease. BMJ 337: a3098-a3098 [Full text]  
• Hall, G H (2008). Which "angiographic positives" will die from heart disease?. BMJ 337: a3100-a3100 [Full text]  
• Abramson, B. (2008). Electrocardiography in suspected angina. BMJ 337: a2340-a2340 [Full text]  

Rapid Responses:

Read all Rapid Responses

The sensitivity and specificity of exercise ECG for significant CAD

Kevin Barraclough
bmj.com, 16 Nov 2008 [Full text]

Re: The sensitivity and specificity of exercise ECG for significant CAD

GH Hall
bmj.com, 18 Nov 2008 [Full text]

Typo?

Mayer Brezis
bmj.com, 28 Nov 2008 [Full text]

Exercise ECGs - any silver linings?

Mark N Upton
bmj.com, 29 Nov 2008 [Full text]

angina and excercise teseting

Henk de Vries, et al.
bmj.com, 29 Nov 2008 [Full text]

Who Should Run Rapid Access Chest Pain Clinics?

Daniel M Sado
bmj.com, 5 Dec 2008 [Full text]

Gender analysis required for prognostic value of the exercise electrocardiogram in the initial assessment of patients with suspected angina

Margaret CP Rees, et al.
bmj.com, 5 Dec 2008 [Full text]

Changes following an exercise test

G J Forbes
bmj.com, 9 Dec 2008 [Full text]

Diagnosis and prognosis

fabrizio Turrini
bmj.com, 23 Dec 2008 [Full text]

Online poll

Find out more on doc2doc >>