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1840 · N Engl J Med, Vol. 344, No. 24 · June 14, 2001 · www.nejm.org
N Engl J Med, Vol. 344, No. 24 · June 14, 2001 · www.nejm.org · 1841
Stress
Reperfusion
use of computerized image enhancement. Apparent phy, concomitant use of beta-blockers and other anti-
perfusion defects can be produced by attenuation ar- anginal medications may compromise the sensitivity
tifacts (e.g., breast tissue and the diaphragm) situated of radionuclide imaging for the detection of coronary
between the heart and the imaging camera. Small artery disease. When possible, such agents should be
differences of up to 25 percent between regions may stopped four or five half-lives before testing.3
represent the normal variation, and the extent of rel- Radionuclide studies also provide prognostic infor-
ative differences can be exaggerated on colored dis- mation beyond that available from clinical evaluations
play scales or by the oversubtraction of adjacent back- and exercise electrocardiography in both men and
ground activity as part of contrast enhancement. women.13-15 However, as is true of exercise electro-
Finally, false positive results may occur if inexperi- cardiography, radionuclide perfusion imaging is less
enced readers interpret regional tracer activity from accurate in women than in men. Some data suggest
computer-derived color images alone and do not study that the better imaging properties of technetium-
the original, unprocessed monochrome planar imag- 99m sestamibi may make it a superior agent for the
es used to generate the SPECT images. evaluation of obese patients or women with large
Although the pharmacologic properties of dobu- breasts or breast implants.16
tamine differ from those of adenosine and dipyrida-
Stress Echocardiography
mole, the diagnostic yield of these agents with respect
to radionuclide perfusion imaging is similar and is also Characteristics
similar to that obtained with exercise scintigraphy.2 Stress echocardiography can involve exercise or
However, dobutamine has not been studied as ex- pharmacologic agents to provoke ischemia.17 Echo-
tensively as the two vasodilators, and it does not cause cardiographic images obtained while the patient is at
as great an increase in coronary flow as the other rest and during or immediately after stress (e.g., one
agents; thus, it is recommended for use when there to two minutes after exercise) are compared side by
are contraindications to the use of adenosine or di- side. A test is considered positive if wall-motion ab-
pyridamole.3 As is true with exercise electrocardiogra- normalities develop with stress in previously normal
1842 · N Engl J Med, Vol. 344, No. 24 · June 14, 2001 · www.nejm.org
vascular territories or worsen in a segment that was et al. concluded that, for patients with typical angina,
abnormal at base line. As is true of radionuclide per- the use of exercise echocardiography instead of ex-
fusion imaging, stress echocardiography provides in- ercise electrocardiography improved survival at a cost
formation on the location and extent of jeopardized of $32,000 per quality-adjusted life-year; for patients
myocardium. In addition, this test provides insight with atypical angina, the cost per quality-adjusted life-
into left ventricular and cardiac-valve function. year was $41,900.22 Exercise SPECT improved out-
Summary of Data
comes in these two populations of patients at costs
of $38,000 and $54,900 per quality-adjusted life-year,
The range of estimates for the diagnostic perform- respectively. These cost-effectiveness ratios are simi-
ance of stress echocardiography varies widely (Table lar to those of other accepted medical interventions.
2), but summary data indicate that its sensitivity is in A second analysis yielded similar findings but con-
the same range as or slightly lower than that of radi- cluded that stress echocardiography was a more cost-
onuclide perfusion imaging.4,7 As is true of other non- effective strategy than SPECT, with total costs equal
invasive tests for ischemia, the test has a higher sensi- to or lower than those of exercise electrocardiogra-
tivity for multivessel disease (about 90 percent) than phy.7 This analysis assumed a higher specificity for
for single-vessel disease (56 percent).3,18 Pooled data stress echocardiography than the prior study22 (88
indicate that exercise echocardiography is more spe- percent vs. 77 percent). Some data support a targeted,
cific than exercise SPECT.19 Dobutamine and dipyrid- staged approach in which exercise electrocardiography
amole stress echocardiography have similar diagnos- is used first, followed by SPECT for patients with an
tic yields.20 intermediate or high risk of complications on the basis
Long-term data demonstrate the prognostic im- of clinical and exercise-electrocardiographic data.15
portance of information obtained from stress echo-
cardiography. Among medically treated patients, the AREAS OF UNCERTAINTY
four-year rate of infarction-free survival was lower in
patients with positive tests than in those with nega- Recommendations regarding the use of these tests
tive tests (87 percent vs. 94 percent).18 These data sug- are based on analyses of observational data, and these
gest that patients with positive tests have a better prog- analyses by necessity include numerous assumptions
nosis if they are treated invasively.18 A negative exercise about subsequent management, outcomes, and costs.
echocardiogram is associated with rates of survival Just as the overall superiority of any testing strategy
without cardiac events of 99.2 percent at one year in the general population has not been proved, the
and 97.4 percent at three years.21 relative effect of these tests in key subgroups (e.g.,
women, the elderly, patients with diabetes, and pa-
Comparative Studies tients who are taking antianginal medications) also
Trials that compare outcomes for patients suspect- has not been tested.
ed of having stable coronary disease who are random-
ly assigned to these three testing strategies have not GUIDELINES
been performed, nor are they likely to be. Such a trial
Guidelines from the American College of Cardi-
would require the enrollment and follow-up of large
ology and the American Heart Association consistent-
numbers of patients, because of the overall excellent
ly advocate exercise electrocardiography as the appro-
prognosis of patients with chronic stable angina, and
priate first test for patients with known or suspected
because variability in management strategies after ini-
chronic stable angina.1-3 Table 1 summarizes the list
tial testing would bias the results in favor of the null
of indications that, according to guidelines issued in
hypothesis. Thus, strategies for the use of these tests
1999, define subgroups of patients who are good can-
must be evaluated on the basis of observational data.
didates for imaging as opposed to exercise electrocar-
Published research consistently demonstrates that
diography.3 These guidelines (which were developed
stress testing with radionuclide scintigraphy and echo-
in conjunction with the American College of Physi-
cardiography provides more information than exercise
cians and the American Society of Internal Medicine)
electrocardiography alone.7,13-15,22 However, the fact
acknowledge that there is uncertainty about the opti-
that a test provides more information does not neces-
mal testing strategies in women, but conclude that
sarily mean it is the most appropriate test. Other im-
there are “currently insufficient data to justify replac-
portant issues are whether the additional information
ing standard exercise testing with stress imaging when
is sufficient to change patient care in ways that would
evaluating women” for coronary artery disease.3
be expected to improve outcomes, and whether those
improvements in outcome can be achieved at a cost CONCLUSIONS AND RECOMMENDATIONS
that is similar to that of other medical interventions.
Two recent analyses of cost effectiveness used ob- There are multiple tests and strategies for the eval-
servational data on outcomes to evaluate various diag- uation of a patient with suspected or known stable
nostic strategies for patients with chest pain.7,22 Kuntz coronary artery disease, and no single test or strategy
N Engl J Med, Vol. 344, No. 24 · June 14, 2001 · www.nejm.org · 1843
REFERENCES
has been proven to be superior overall. Imaging is
clearly appropriate for patients with uninterpretable 1. Gibbons RJ, Balady GJ, Beasley JW, et al. ACC/AHA guidelines for ex-
electrocardiograms, and a pharmacologic agent is the ercise testing: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines (Committee on Ex-
most effective way to provoke ischemia in patients ercise Testing). J Am Coll Cardiol 1997;30:260-311.
with poor functional status and in some patients who 2. Ritchie JL, Bateman TM, Bonow RO, et al. Guidelines for clinical use
of cardiac radionuclide imaging: report of the American College of Cardi-
are unable to raise their heart rate as a result of med- ology/American Heart Association Task Force on Assessment of Diagnos-
ications (e.g., beta-blockers) or conduction-system tic and Therapeutic Cardiovascular Procedures (Committee on Radionu-
disease. In other patients, however, the choice between clide Imaging), developed in collaboration with the American Society of
Nuclear Cardiology. J Am Coll Cardiol 1995;25:521-47.
exercise electrocardiography and an imaging test 3. Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP-ASIM
should be influenced by factors such as the diagnos- guidelines for the management of patients with chronic stable angina: a re-
tic yield, costs, and convenience. Regardless of which port of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines. J Am Coll Cardiol 1999;33:2092-197.
test is used, a normal result should never be consid- [Erratum, J Am Coll Cardiol 1999;34:314.]
ered a guarantee that the patient does not have coro- 4. Cheitlin MD, Alpert JS, Armstrong WF, et al. ACC/AHA guidelines for
the clinical application of echocardiography: a report of the American Col-
nary disease or has no risk of cardiovascular events. lege of Cardiology/American Heart Association Task Force on Practice
Our approach to the use of these tests is as follows. Guidelines (Committee on Clinical Application of Echocardiography): de-
In a patient with newly diagnosed or suspected cor- veloped in collaboration with the American Society of Echocardiography.
Circulation 1997;95:1686-744.
onary artery disease, we recommend imaging as the 5. Pina IL, Balady GJ, Hanson P, Labovitz AJ, Madonna DW, Myers J.
first test if the electrocardiogram is uninterpretable Guidelines for clinical exercise testing laboratories: a statement for health-
or the patient cannot exercise sufficiently. We also care professionals from the Committee on Exercise Testing and Cardiac
Rehabilitation, American Heart Association. Circulation 1995;91:912-
recommend imaging in patients with poor myocar- 21.
dial function or a history of revascularization if the 6. Stuart RJ Jr, Ellestad MH. National survey of exercise stress testing fa-
cilities. Chest 1980;77:94-7.
goal is to assess myocardial viability. If none of these 7. Garber AM, Solomon NA. Cost-effectiveness of alternative test strate-
factors are present, as in the patient described in the gies for the diagnosis of coronary artery disease. Ann Intern Med 1999;
initial case vignette, then we recommend exercise elec- 130:719-28.
8. Gianrossi R, Detrano R, Mulvihill D, et al. Exercise-induced ST depres-
trocardiography as the first test for general diagnostic sion in the diagnosis of coronary artery disease: a meta-analysis. Circulation
and prognostic assessment. The choice of imaging test 1989;80:87-98.
(echocardiography vs. radionuclide imaging) should 9. Froelicher VF, Lehmann KG, Thomas R, et al. The electrocardiographic
exercise test in a population with reduced workup bias: diagnostic perform-
take into consideration the test that is most trusted ance, computerized interpretation, and multivariable prediction. Ann In-
and available at a given institution. These recommen- tern Med 1998;128:965-74.
10. Mark DB, Shaw L, Harrell FE Jr, et al. Prognostic value of a treadmill
dations reflect variability in the performance of these exercise score in outpatients with suspected coronary artery disease.
tests at different laboratories, which leads to uncer- N Engl J Med 1991;325:849-53.
tainty about the relevance of published cost-effec- 11. Dilsizian V, Rocco TP, Freedman NMT, Leon MB, Bonow RO. En-
hanced detection of ischemic but viable myocardium by the reinjection of
tiveness analyses of these tests7,22 in all settings. thallium after stress–redistribution imaging. N Engl J Med 1990;323:141-
The results of imaging tests may also refine prog- 6.
nostic assessments based on initial clinical assessments, 12. Mahmarian JJ, Verani MS. Exercise thallium-201 perfusion scintigra-
phy in the assessment of coronary artery disease. Am J Cardiol 1991;67:
including exercise electrocardiography. Data from ex- 2D-11D.
ercise electrocardiography can be used to classify pa- 13. Hachamovitch R, Berman DS, Kiat H, et al. Exercise myocardial per-
fusion SPECT in patients without known coronary artery disease: incre-
tients according to the risk of complications with the mental prognostic value and use in risk stratification. Circulation 1996;93:
use of tools such as the Duke treadmill score.10 On 905-14.
the basis of these data, low-risk patients are those with 14. Berman DS, Hachamovitch R , Kiat H, et al. Incremental value
of prognostic testing in patients with known or suspected ischemic heart
a high heart rate and cardiovascular workload on ex- disease: a basis for optimal utilization of exercise technetium-99m sesta-
ercise testing, no angina, and minimal ischemia or mibi myocardial perfusion single-photon emission computed tomography.
none at all. This group of patients has an excellent J Am Coll Cardiol 1995;26:639-47. [Erratum, J Am Cardiol 1996;27:
756.]
prognosis, and the results of imaging tests are un- 15. Hachamovitch R, Berman DS, Kiat H, et al. Effective risk stratifica-
likely to lead to changes in therapy. In contrast, high- tion using exercise myocardial perfusion SPECT in women: gender-related
differences in prognostic nuclear testing. J Am Coll Cardiol 1996;28:34-
risk patients are those with marked myocardial ische- 44.
mia at low peak workloads, and aggressive treatment, 16. Smanio PE, Watson DD, Segalla DL, Vinson EL, Smith WH, Beller
including coronary revascularization, should be con- GA. Value of gating of technetium-99m sestamibi single-photon emission
computed tomographic imaging. J Am Coll Cardiol 1997;30:1687-92.
sidered in these patients. The results of imaging tests 17. Rodgers GP, Ayanian JZ, Balady G, et al. American College of Cardiolo-
are unlikely to influence the decision to recommend gy/American Heart Association clinical competence statement on stress test-
cardiac catheterization, although such tests may help ing: a report of the American College of Cardiology/American Heart Associ-
ation/American College of Physicians-American Society of Internal Medicine
pinpoint the ischemic zone in patients in whom an- Task Force on Clinical Competence. Circulation 2000;102:1726-38.
gioplasty or stenting is contemplated for multiple cor- 18. Cortigiani L, Picano E, Landi P, et al. Value of pharmacologic stress
echocardiography in risk stratification of patients with single-vessel disease:
onary stenoses. The group at intermediate risk in- a report from the Echo-Persantine and Echo-Dobutamine International
cludes many patients with moderate exercise capacity, Cooperative Studies. J Am Coll Cardiol 1998;32:69-74.
subtle evidence of ischemia, or atypical chest pain. 19. Fleischmann KE, Hunink MG, Kuntz KM, Douglas PS. Exercise ech-
ocardiography or exercise SPECT imaging? A meta-analysis of diagnostic
In such patients, an imaging test may clarify the di- test performance. JAMA 1998;280:913-20.
agnosis and provide insight into the prognosis. 20. Pingitore A, Picano E, Varga A, et al. Prognostic value of pharmaco-
1844 · N Engl J Med, Vol. 344, No. 24 · June 14, 2001 · www.nejm.org
logical stress echocardiography in patients with known or suspected coro- exercise echocardiography and predictors of subsequent cardiac events: fol-
nary artery disease: a prospective, large-scale, multicenter, head-to-head low-up of 1,325 patients. J Am Coll Cardiol 1998;31:144-9.
comparison between dipyridamole and dobutamine test. J Am Coll Cardiol 22. Kuntz KM, Fleischmann KE, Hunink MGM, Douglas PS. Cost-effec-
1999;34:1769-77. tiveness of diagnostic strategies for patients with chest pain. Ann Intern
21. McCully RB, Roger VL, Mahoney DW, et al. Outcome after normal Med 1999;130:709-18.
N Engl J Med, Vol. 344, No. 24 · June 14, 2001 · www.nejm.org · 1845