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Stress-ECG vs. CT coronary angiography for the diagnosis of coronary artery disease: a “real-world” experience

Stress-ECG vs coronarografia TC nella diagnostica della malattia coronarica: esperienza nel “mondo reale”

  • Cardiac Radiology/Cardioradiologia
  • Published:
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Abstract

Purpose

This study aimed to evaluate the diagnostic accuracy of stress electrocardiogram (ECG) and computed tomography coronary angiography (CTCA) for the detection of significant coronary artery stenosis (≥50%) in the real world using conventional CA as the reference standard.

Materials and methods

A total of 236 consecutive patients (159 men, 77 women; mean age 62.8±10.2 years) at moderate risk and with suspected coronary artery disease (CAD) were enrolled in the study and underwent stress ECG, CTCA and CA. The CTCA scan was performed after i.v. administration of a 100-ml bolus of iodinated contrast material. The stress ECG and CTCA reports were used to evaluate diagnostic accuracy compared with CA in the detection of significant stenosis ≥50%.

Results

We excluded 16 patients from the analysis because of the nondiagnostic quality of stress ECG and/or CTCA. The prevalence of disease demonstrated at CA was 62% (n=220), 51% in the population with comparable stress ECG and CTCA (n=147) and 84% in the population with equivocal stress ECG (n=73). Stress ECG was classified as equivocal in 73 cases (33.2%), positive in 69 (31.4%) and negative in 78 (35.5%). In the per-patient analysis, the diagnostic accuracy of stress ECG was sensitivity 47%, specificity 53%, positive predictive value (PPV) 51% and negative predictive value (NPV) 49%. On stress ECG, 40 (27.2%) patients were misclassified as negative, and 34 (23.1%) patients with nonsignificant stenosis were overestimated as positive. The diagnostic accuracy of CTCA was sensitivity 96%, specificity 65%, PPV 74% and NPV 94%. CTCA incorrectly classified three (2%) as negative and 25 (17%) as positive. The difference in diagnostic accuracy between stress ECG and CTCA was significant (p<0.01).

Conclusions

CTCA in the real world has significantly higher diagnostic accuracy compared with stress ECG and could be used as a first-line study in patients at moderate risk.

Riassunto

Obiettivo

Scopo del presente lavoro è stato valutare l’accuratezza diagnostica dell’elettrocardiogramma sotto stress (stress-ECG) e dell’angiografia coronarica con tomografia computerizzata (CT-CA) nell’individuazione delle stenosi coronariche significative (riduzione del lume coronarico ≥50%) vs l’angiografia coronaria convenzionale (CAG) basando la valutazione sulla refertazione clinica.

Materiali e metodi

Duecentotrentasei pazienti consecutivi (159 maschi, 77 femmine, età media 62,8±10,2 anni) a rischio intermedio con sospetta malattia coronarica sono stati arruolati per lo studio e sottoposti a stress-ECG, CT-CA e CAG. Per la scansione CT-CA sono stati iniettati endovena 100 ml di mezzo di contrasto. Tutti i pazienti sono stati quindi sottoposti a CAG. I referti dello stress-ECG e della CT-CA sono stati confrontati con la CAG quantitativa per la valutazione dell’accuratezza diagnostica.

Risultati

Sedici pazienti sono stati esclusi dall’analisi per stress-ECG e/o CT-CA di qualità inadeguata. La prevalenza di malattia è risultata del 62% nella popolazione complessiva (n=220), del 51% nella popolazione con stress-ECG e CT-CA confrontabili (n=147), e dell’84% nella popolazione con stress-ECG dubbio (n=73). Settantatre (33,2%) stress-ECG sono stati classificati come dubbi, 69 (31,4%) sono stati classificati come positivi e 78 (35,5%) sono stati classificati come negativi. Nell’analisi per paziente i valori dell’accuratezza diagnostica dello stress-ECG sono risultati: sensibilità 47%, specificità 53%, valore predittivo positivo 51%, valore predittivo negativo 49%. Quaranta (27,2%) pazienti sono stati erroneamente classificati come negativi. Trentaquattro (23,1%) pazienti che non avevano stenosi significative sono stati incorrettamente classificati come positivi. I valori dell’accuratezza diagnostica della CT-CA sono risultati: sensibilità 96%, specificità 65%, valore predittivo positivo 74%, valore predittivo negativo 94%. Tre (2%) pazienti sono stati erroneamente classificati come negativi. Venticinque (17%) pazienti che non avevano stenosi significative sono stati incorrettamente classificati come positivi. La differenza di accuratezza diagnostica è risultata significativa (p<0,01).

Conclusioni

La CT-CA nel mondo reale mostra una accuratezza diagnostica significativamente superiore allo stress-ECG e potrebbe essere utilizzata in prima istanza nei pazienti a rischio intermedio.

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Authors and Affiliations

  1. Dipartimento di Radiologia e Cardiologia, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy

    E. Maffei, A. Palumbo, C. Martini, A. Cuttone, F. Ugo, E. Emiliano, A. Menozzi, L. Vignali, V. Brambilla, P. Coruzzi, C. Reverberi, G. Crisi & F. Cademartiri

  2. Dipartimento di Radiologia e Cardiologia, Erasmus Medical Center, Rotterdam, The Netherlands

    A. Palumbo, C. Martini, A. Weustink, N. Mollet, D. Ardissino & F. Cademartiri

  3. Dipartimento di Radiologia e Diagnostica per Immagini, Azienda Ospedaliero-Universitaria di Parma, c/o Piastra Tecnica, Piano 0, Via Gramsci 14, 43100, Parma, Italy

    F. Cademartiri

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  1. E. Maffei
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  2. A. Palumbo
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  9. V. Brambilla
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  14. C. Reverberi
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  15. G. Crisi
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Correspondence to F. Cademartiri.

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Maffei, E., Palumbo, A., Martini, C. et al. Stress-ECG vs. CT coronary angiography for the diagnosis of coronary artery disease: a “real-world” experience. Radiol med 115, 354–367 (2010). https://doi.org/10.1007/s11547-009-0456-9

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  • DOI: https://doi.org/10.1007/s11547-009-0456-9

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