Coronary heart disease: adding right precordial to standard ECG leads was a diagnostically useful.

Clinical bottom line (level 1b)

  1. 85% of patients referred for coronary arteriography had coronary artery disease.
  2. A 12 lead ECG plus three right precordial leads were very helpful in ruling out coronary artery disease (sensitivity 92%).
  3. Adding thallium-201 scintigraphy did not improve the test sensitivity greatly (sensitivity 93%).
Michaelides et al: New England Journal of Medicine 1999; 340 (5): 340-345
Expires January 2003

The study

Setting: general hospital, Greece

245 patients (aged range 32 to 74 years; mean 52, 89% male) referred with symptoms resembling angina

Excluded if
  • left or right bundle branch block
  • left or right ventricular hypertrophy
  • ventricular preexcitation
  • history of MIor valvular or congestive heart disease
  • undergone aortocoronary bypass surgery or coronary angioplasty
  • receiving digitalis
  • inconclusive ECG results
  • patients who refused coronary arteriography


    • All medication was stopped at least five half-lives before exercise testing.
    Independent blinded reference standard, applied in all patients from a consecutive appropriate spectrum.
    Reference standard:
    • coronary arteriography and left ventriculography- coronary artery disease was diagnosed if there was a narrowing of 70% or more of the diameter of the lumen in the left anterior descending, left circumflex or right coronary artery or narrowing of 50% or more in the left main coronary artery.
    Diagnostic test: exercise echocardiography incorporating right precordial leads (V3R, V4R, V5R) and thallium-201 scintigraphy- patients exercised on a treadmill, and the test was considered negative for ischaemia when the heart rate reached at least 85% of the maximal predicted value in the absence of ischaemic ST-segment changes

    The evidence


    diagnostic test number of patients sensitivity for
    coronary artery disease
    (95% CI)    		 LR+ LR-
    standard 12 lead ECG 139 65.9%
    (54.5% to 72.3%)
    standard 12 lead ECG plus right precordial leads 195 92.4%
    (88.8% to 96.0%)
    12 standard leads, right precordial leads plus thallium-201 scintigraphy 196 92.9%
    (89.4% to 96.4%)
    total 211

    Citation

    1. Michaelides AP, Psomadaki ZD, Dilaveris PE, et al: Improved detection of coronary artery disease by exercise electrocardiography with the use of right precordial leads. New England Journal of Medicine 1999; 340 (5): 340-345
    Contributor: Chris Ball and Clare Wotton, January 2000
    Reviewer: William Rhoton

    Clinical Question.
    Patient suspected coronary artery disease
    Intervention or Exposure exercise echocardiography with right precordial leads
    Comparison arteriography
    Outcome diagnosis