Elsevier

American Heart Journal

Volume 147, Issue 6, June 2004, Pages 1085-1092
American Heart Journal

Clinical investigations: imaging and diagnostic testing
Validation of the accuracy of pretest and exercise test scores in women with a low prevalence of coronary disease: the NHLBI-sponsored Women's Ischemia Syndrome Evaluation (WISE) study

https://doi.org/10.1016/j.ahj.2003.12.034Get rights and content

Abstract

Background

Recently revised American College of Cardiology/American Heart Association guidelines have suggested that exercise test scores be used in decisions concerning patients with suspected coronary artery disease (CAD). Pretest and exercise test scores derived for use in women without known CAD have not been tested in women with a low prevalence of CAD.

Methods

Within the Women's Ischemia Syndrome Evaluation (WISE) study, we evaluated 563 women undergoing coronary angiography for suspected myocardial ischemia. The prevalence of angiographic CAD was 26%. Overall, 189 women underwent treadmill exercise testing. Prognostic end points included death, myocardial infarction, stroke, and revascularization.

Results

Each score stratified women into 3 probability groups (P <.001) according to the prevalence of coronary disease: Pretest: low 20/164 (12%), intermediate 53/245 (22%), high 75/154 (49%); Exercise test: low 11/83 (13%), intermediate 22/74 (30%), high 17/32 (53%). However, the Duke score did not stratify as well: low 7/46 (15%), intermediate 36/126 (29%), high 6/17 (35%); P = .44. When pretest and exercise scores were considered together, the best stratification with the exercise test score was in the intermediate pretest group (P < .03). The Duke score did not stratify this group at all (P = .98). Pretest and exercise test scores also stratified women according to prognostic end points: pretest—low 7/164 (4.3%), intermediate 28/245 (11.4%), high 27/154 (17.5%), P < .01; exercise test—low 4/83 (4.8%) and intermediate-high 17/106 (16%), P = .014.

Conclusion

Both pretest and exercise test scores performed better than the Duke score in stratifying women with a low prevalence of angiographic CAD. The exercise test score appears useful in women with an intermediate pretest score, consistent with American College of Cardiology/American Heart Association guidelines.

Section snippets

Patient population

The WISE study is a National Heart, Lung, and Blood Institute sponsored 4-center study that aims to improve the diagnostic reliability of cardiovascular testing in the evaluation of ischemic heart disease in women. Women with chest pain symptoms or suspected ischemia undergo an initial evaluation that includes the collection of demographic, medical history, and risk factor data. The complete study design and methodology of the WISE study are described elsewhere.5

We excluded from this analysis

Patient populations

Table Iincludes a summary of clinical and exercise test characteristics and the 3 scores considered. In the pretest score group, coronary disease was found in 148 of 563 women or 26.2%. In the new exercise score group, coronary disease was found in 50 of 189 women or 26.5%. Prevalences within predetermined probability subgroups (Figure 1) for all 3 scores are displayed on Table II. With the exception of the Duke score, stratification by both coronary disease presence and multivessel disease on

Discussion

Exercise ST segment responses in women are associated with both lower sensitivity and specificity rates than in men,15 even when post-test referral bias is considered.16 Despite these differences in ST segment response accuracy, incorporation of ST responses into multivariable models with clinical and other exercise test variables leads to similar accuracy in men and women.7, 14 Previous validation of both the pretest and exercise scores3, 4 demonstrated qualitatively similar results to this

References (20)

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Supported by NHLBI contracts (N01-HV-68161, N01-HV-68162, N01-HV-68163, N01-HV-68164 and U01-HL64829-01, U01-HL64914-01, U01-HL64924-01) and grants from the Gustavus and Louis Pfieffer Research Foundation, Danville, NJ, the Women's Guild of Cedars-Sinai Medical Center, Los Angeles, Calif, the Ladies Hospital Aid Society of Western Pennsylvania, Pittsburgh, Pa, and QMED Inc, Laurence Harbor, NJ.

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