In Search of the False‐negative Exercise Treadmill Testing Evidence‐based Use of Exercise Echocardiography

Abstract

SummaryBackground: Controversy exists regarding the role of exercise treadmill testing (ETT) versus exercise stress echocardiography (ESE) as the appropriate initial noninvasive test to risk-stratify patients with chest pain. The majority of studies to date that evaluated these methodologies included patients with poor functional status and baseline electrocardiogram (ECG) abnormalities, potentially limiting the sensitivity of ETT.Hypothesis: We examined the hypothesis that given stringent standards of exercise duration and ECG interpretability, the ETT would have a high diagnostic sensitivity for the presence of significant coronary artery disease (CAD).Methods: Results of concurrent ETT and ESE in 3,098 patients were examined, and the subset of patients with a negative ETT and positive ESE (−ETT/+ESE) were reviewed for the presence of CAD as a function of exercise duration (< or ≥ 6 min) and baseline ECG normality.Results: In those patients with a −ETT/+ESE who exercised ≥ 6 min, 54 had a normal baseline ECG, 22 underwent angiography and 6 had CAD (all of whom had either small, grafted or collateralized vessels). Patients with a −ETT/+ESE who were incapable of exercising 6 min were more frequently older and female. Mortality was significantly greater in the < 6 min exercise duration group (31.4 versus 3.1%).

Diagnostic accuracy of exercise stress testing for coronary artery disease: a systematic review and meta-analysis of prospective studies

“…Upon additional review of full‐text articles, 34 studies with 3,352 participants were included in the systematic review (20–53). Studies excluded at the second stage are listed in the reference list (54–124). Table 1 shows that the vast majority of the included studies were from Western Europe and North America (13 from the United States).…”

Prediction of Mortality and Major Cardiac Events by Exercise Echocardiography in Patients With Normal Exercise Electrocardiographic Testing

“…Current American Heart Association/American College of Cardiology practice guidelines (1,2,23) recommend exercise ECG testing as the preferred initial noninvasive test for the diagnosis and risk stratification of patients with normal resting ECG and suspected CAD in the absence of treatment with digoxin. The main argument against the routine performance of stress imaging procedures in patients with interpretable ECG is a higher cost and lower yield of such strategy (24,25). However, EE has lower cost than other noninvasive imaging techniques, and it is not clear whether the lower initial cost of exercise ECG testing translates into a lower overall cost of patient care.…”

Diagnostic value of electrocardiogram stress testing in patients with metabolic syndrome

“…However, Grünig et al stated that stress echocardiography adds little diagnostic information to ECG stress testing findings in unselected outpatients and it should not replace ECG stress test in cardiac screening [28]. Moreover, ECG stress testing may be initial diagnostic method in patients with chest pain having normal baseline ECG and functional capacity, whereas stress echocardiography may be more preferred in cases with abnormal baseline ECG and inability to exercise [29]. The diagnostic accuracy of SPECT has been also recognized to be superior to that of ECG stress testing (86.3% vs. 80.3%) [30], as well as the prognostic value of CCTA [31,32].…”