Chest
Volume 119, Issue 6, June 2001, Pages 1933-1940
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Exercise and the Heart
Simple Treadmill Score To Diagnose Coronary Disease

https://doi.org/10.1378/chest.119.6.1933Get rights and content

Objective

Our aim was to derive and validate a simplified treadmill score for predicting the probability of angiographically confirmed coronary artery disease (CAD).

Background

The American College of Cardiology/American Heart Association guidelines for exercise testing recommend the use of multivariable equations to enhance the diagnostic characteristics of the standard treadmill test. Most of these equations use complicated statistical techniques to provide diagnostic estimates of CAD. Simplified scores derived from such equations that require physicians only to add points have been developed for pretest estimates of disease and for prognosis. However, no simplified score has been developed specifically for the diagnosis of CAD using exercise test results.

Methods

Consecutive patients referred for evaluation of chest pain who underwent standard treadmill testing followed by coronary angiography were studied. A logistic regression model was used to predict clinically significant (≥ 50% stenosis) CAD and then the variables and coefficients were used to derive a simplified score. The simplified score was calculated as follows: (6 × maximal heart rate code) + (5 × ST-segment depression code)+(4 × age code) + angina pectoris code + hypercholesterolemia code + diabetes code + treadmill angina index code. The simplified score had a range from 6 to 95, with < 40 designated as low probability, between 40 and 60 was intermediate probability, and > 60 was high probability for CAD.

Results

A total of 1,282 male patients without a prior myocardial infarction underwent exercise treadmill testing and coronary angiography in the derivation group, and there were 476 male patients in the validation group from another institution. The area under the receiver operating characteristic curve (± SE) for the ST-segment response alone was 0.67 as compared to 0.79 ± 0.01 for the diagnostic score (p > 0.001). The prevalence of significant disease for the men was 27% in the low-probability group, 62% in the intermediate-probability group, and 92% in the high-probability group, which was similar to the prevalence in the validation group, with 22%, 58%, and 92% in low-, intermediate-, and high-probability groups, respectively. The low-probability group had< 4% prevalence of severe disease. In both populations, 7 more patients out of 100 were correctly classified than with the use of ST-segment criteria. When used as a clinical man agement strategy, the score has a sensitivity of 88% and a specificity of 96%.

Conclusion

This simplified exercise score that estimates the probability of CAD can be easily applied without a calculator and is a useful and valid tool that can help physicians man age patients presenting with chest pain.

Section snippets

Veterans Affairs Score Development Population

Eight thousand male patients underwent treadmill testing at two Veterans Affairs (VA) medical centers between 1987 and 1998. Of these patients, 3,454 were evaluated for chest pain with coronary angiography within 3 months of treadmill testing. Patients with previous cardiac surgery or angiography, valvular heart disease, left bundle-branch block, paced rhythms, or Wolff-Parkinson-White syndrome on their resting ECG were excluded from the study. Since neither medications nor resting ST-segment

Population Characteristics

Of the 1,282 veterans included in this study, 759 patients (59%) had clinically significant CAD, 302 patients (24%) had multivessel disease, and 523 patients (41%) were without any CAD; the 476 men in the validation group from West Virginia University Medical Center had a 46% prevalence of CAD (Table 1) . Overall, the CAD group of patients was older compared to patients without CAD in both the populations. The CAD groups had a higher prevalence of hypertension, diabetes, and

Discussion

Recommendations have been made for assigning patients to low-, intermediate-, or high-probability groups based on clinical criteria in order to provide a strategy for patient man agement.21 The use of a score for diagnostic purposes represents a compromise between the simplicity of designating arbitrary high probability, intermediate and low probability, and the accuracy of detailed logistic regression models.22 Probability of disease subgrouping is appealing because the classification scheme

Conclusion

This clinical scoring method is an accurate and simple method for categorizing patients with suspected coronary disease into clinically meaningful groups for which decisions concerning patient man agement can be based. We have demonstrated that the score is portable and is diagnostically superior to standard exercise testing interpretation.

Morise Pretest Score

age code + (angina pectoris code × 5) + (diabetes × 2) + hypertension + smoking now + hypercholesterolemia + family history of CAD + obesity,

where age < 40 = 3 points, age between 40 years and 55 years = 6 points, and age > 55 years = 9 points. For estrogen status, 3 points were subtracted for positive status and 3 points were added for negative status. Typical chest pain = 5 points, atypical chest pain = 3 points, nonanginal chest pain = 1 point, and no chest pain = 0 points. For diabetes

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