Coronary heart disease: exercise echocardiography and exercise SPECT help to diagnose.

Clinical bottom line (level 1a)

  1. Between two-thirds and three-quarters of patients with suspected coronary artery disease sent for SPECT or exercise echocardiography have it.
  2. Patients with suspected coronary artery disease who have a positive exercise echocardiograph are slightly more likely to have it (LR+3.26) , and those with a negative result are less likely to have it (LR-0.16) . It appears a better test than SPECT.
  3. Patients who have a positive exercise SPECT are slightly more likely to have it (LR+2.19) , and those with a negative result are less likely to have it (LR-0.18) .
Fleischmann et al: Journal of the American Medical Association 1998; 280 (10): 913-920
Expires March 2003

The study

Systematic review of Studies of
  • Patients: suspected coronary artery disease
  • Intervention: exercise single-photon emission computed tomography (SPECT) or exercise echocardiography compared with coronary angiography
  • Outcome: diagnosis


    • Articles found in English using MEDLINE, January 1990 to October 1997 (search terms: coronary disease and exercise test AND echocardiography, thallium or thallium radioisotopes, or sestamibi and restricted by the term human. ) and Bibliographies of original and review articles were handsearched and experts in each area were contacted.

    Selection criteria: as above
    Appraisal criteria: detailed in text
    Articles excluded if: studies where absolute numbers for true-positive, true-negative, false-positive and false-negative were not available, studies performed exclusively on patients after MI, after percutaneous transluminal coronary angioplasty or coronary artery bypass grafting, or with unstable coronary syndromes.

    44 articles were included (24 reported exercise echocardiography and 27 exercise SPECT).

    The evidence


    diagnostic test coronary artery disease no coronary artery disease LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    exercise echocardiography 1495 202 3.26
    (2.93 to 3.62)     		85.0% 0.16
    (0.14 to 0.19)     		23.0%
    exercise SPECT 2209 257 2.19
    (2.01 to 2.38)     		87.0% 0.18
    (0.16 to 0.20)     		36.0%
    total - -

    • In the exercise echocardiography results, there were 1750 patients with coronary artery disease and 890 without. In the exercise SPECT results, there were 2525 with disease and 712 without.

    Comments

    1. The pre-test probability for the echocardiography data was 64% and for the SPECT data was 76%.
    2. For clinicians with both tests available to them, the results of this meta-analysis should be applied cautiously, since local expertise might be substantially different from expertise in centers where this research was performed.

    Citation

    1. Fleischmann KE, Hunink MGM, Kuntz KM, et al: Exercise echocardiography or exercise SPECT imaging?: A meta-analysis of diagnostic test performance. Journal of the American Medical Association 1998; 280 (10): 913-920
    Contributor: Clare Wotton and Musab Hayatli, January 2000
    Reviewer: Edward Havranek

    Clinical Question.
    Patient coronary artery disease
    Intervention or Exposure exercise SPECT or exercise echocardiography
    Comparison coronary angiography
    Outcome diagnosis