Coronary artery disease: age and symptoms increased the risk.

Clinical bottom line (level 2a)

Patients with >2.5 mm non sloping ST depression on stress ECG were much more likely to have coronary artery disease (LR+39) .
Patients with three coronary calcification vessels on cardiac fluoroscopy have coronary artery disease.
Reversible perfusion defect on stress thallium scintigraphy makes coronary artery disease more likely (LR+12) .
Patients are more likely to have coronary artery disease if they are older than 60 and have three anginal symptoms.

Diamond and Forrester: New England Journal of Medicine 1979; 300 (24): 1350-1358

Expires July 2003

The study

Systematic review of unknown of

Patients: angina or non anginal chest pain
Intervention: symptoms, stress ECG, cardiac fluoroscopy, cardio kymographic stress, stress thallium scintigraphy
Outcome: probability of coronary artery disease

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Selection criteria: not known
Appraisal criteria: no formal appraisal noted
Articles excluded if:

not clear how many studies were included
No test for heterogeneity.

The evidence

diagnostic test	LR (95% CI)	post-test probability
>2.5 mm non sloping ST depression	39 ( to )	98%
2.0-2.5 non sloping ST depression	11 ( to )	92%
1.5-2.0 mm non sloping ST depression	4.2 ( to )	81%
1.0-1.5 mm non sloping ST depression on stress ECG	2.1 ( to )	69%
0.5-1.0 mm non sloping ST depression	0.92 ( to )	49%
<0.5 mm non sloping ST depression	0.23 ( to )	19%
3 coronary calcification vessels on cardiac fluoroscopy	inf ( to )	100%
reversible perfusion defect on stress thallium scintigraphy	12 ( to )	93%
fixed perfusion defect	1.4 ( to )	59%
no perfusion defect	0.18 ( to )	16%
total

Risk of significant coronary artery disease (50% or more coronary artery stenosis in at least one major artery) with any of the following symptoms:
- retrosternal chest pain
- pain brought on by exertion
- pain relieved in <10 minutes by rest or nitroglycerin
Probability in men who are asymptomatic (0 symptoms):
- aged 30-39: 2%
- 40-49: 6%
- 50-59: 10%
- 60-69: 12%
Probability in men with non-anginal chest pain (1 symptom):
- 30-39: 5%
- 40-49: 14%
- 50-59: 22%
- 60-69: 28%
Probability in men with atypical angina (2 symptoms):
- 30-39: 22%
- 40-49: 46%
- 50-59: 59%
- 60-69: 67%
Probability in men with typical nag ina (all 3 symptoms):
- 30-39: 70%
- 40-49: 87%
- 50-59: 92%
- 60-69: 94%
Probability in asymptomatic women:
- 30-39: 0.3%
- 40-49: 1%
- 50-59: 3%
- 60-69: 8%
Probability in women with non-anginal chest pain:
- 30-39: 1%
- 40-49: 3%
- 50-59: 8%
- 60-69: 19%
Probability in women with atypical angina:
- 30-39: 4%
- 40-49: 13%
- 50-59: 32%
- 60-69: 54%
Probability in women with typical angina:
- 30-39: 26%
- 40-49: 55%
- 50-59: 79%
- 60-69: 91%

Comments

Limitations include firstly, the data used to determine prevalence, sensitivity, and specificity are somewhat dated and the search methods not outlined rigorously. Second, the diagnostic tests used including cardiac fluoroscopy and cardio kymographic stress tests are not routinely used any longer.
However, these do not detract from the take home message; that the practicing clinician can roughly estimate the pre-test probability of coronary artery disease based on established risk factors.

Citation

Diamond GA, and Forrester JS: Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. New England Journal of Medicine 1979; 300 (24): 1350-1358

Contributor: Clare Wotton and Chris Ball, July 2000
Reviewer: Kenneth Ballew

_{Clinical Question.}

_Patient	_{angina or non anginal chest pain}
_{Intervention or Exposure}	_{stress ECG, cardio kymography, thallium scintigraphy and cardiac fluoroscopy}
_Outcome	_{diagnosis of coronary artery disease}