Chest pain: stress testing could help diagnose multivessel ischaemic heart disease.

Clinical bottom line (level 1b)

  1. In patients with chest pain referred for further investigation, exercise testing was not helpful at identifying patients with multivessel ischaemic heart disease.
  2. MIBI or echocardiogram stress testing were better at helping to diagnose multivessel ischaemic heart disease.
  3. If both were negative, multivessel ischaemic heart disease was less likely (LR-0.29) . However, these methods may only exclude disease in patients considered to be at low risk.
Khattar et al: Heart 1998; 79: 274-280
Expires March 2003

The study

Setting: university hospital, UK

100 patients (aged mean 62 years, 70% male) chest pain undergoing exercise ECG and coronary angiography for diagnosis

Excluded if
  • MI within 30 days
  • unstable angina
  • significant arrhythmias
  • heart failure
  • cardiomyopathy
  • significant valvular disease
  • uncontrolled hypertension


    • Patients had beta-blockers and heart-rate-lowering calcium antagonists withdrawn 24 hours before stress testing.
    Independent blinded reference standard, applied in all patients from a consecutive appropriate spectrum.
    Reference standard:
    • coronary angiography
    Diagnostic test: 1. exercise testing- positive if ST depression 2 mm or more, ST depression 1 mm or more in five or more leads, workload <6 metabolic equivalents or significant hypotension (fall in systolic blood pressure >20 mmHg compared with previous stage). Test was terminated if angina, dyspnoea, fatigue or ST depression. 2. inotropic stress imaging- using dobutamine or arbutamine. During infusion, patients had:
    • echocardiography after three minutes, at peak stress, and at ten minutes into recovery period- positive if resting or stress-inducing wall thickening of left ventricle
    • MIBI scanning- using Tc-99m- positive if resting or stress inducing perfusion deficit

    The evidence

    pre-test probability of multivessel ischaemic heart disease: 56%, (95% CI: 46% to 66%)

    diagnostic test multivessel ischaemic heart disease no multivessel ischaemic heart disease LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    exercise ECG 39 26 1.2
    (0.87 to 1.6)     		60% 0.74
    (0.44 to 1.3)     		49%
    MIBI 38 12 2.5
    (1.5 to 4.2)     		76% 0.44
    (0.29 to 0.67)     		36%
    echocardiography 38 8 3.7
    (1.9 to 7.2)     		83% 0.39
    (0.26 to 0.59)     		33%
    MIBI + echo 46 17 2.1
    (1.4 to 3.2)     		73% 0.29
    (0.16 to 0.53)     		27%
    total 56 44

    • Studies also failed to show that chest pain lasting >60 minutes and chest pain of sudden onset as being predictive of MI.

    Comments

    1. Multivariate regression analysis showed that MIBI and echocardiogram stress testing were independently predictive of multivessel ischaemic heart disease.

    Citation

    1. Khattar RS, Senior R, Lahiri A: Assessment of myocardial infarction perfusion and contractile dysfunction by inotropic stress Tc-99m sestambi SPECT imaging and echocardiography for optimal detection of multivessel coronary artery disease. Heart 1998; 79: 274-280
    Search Terms: from other articles noted in ACP Journal Club
    Contributor: Chris Ball and Clare Wotton, July 2000
    Reviewer: William Rhoton

    Clinical Question.
    Patient chest pain
    Intervention or Exposure stress testing
    Outcome diagnosis of multivessel ischaemic heart disease