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. 2007 Jun;23(8):641-7.
doi: 10.1016/s0828-282x(07)70226-x.

High probability of disease in angina pectoris patients: is clinical estimation reliable?

Poul F Høilund-Carlsen  1 , Allan Johansen, Werner Vach, Henrik Wulff Christensen, Mette Møldrup, Torben Haghfelt
Affiliations

High probability of disease in angina pectoris patients: is clinical estimation reliable?

Poul F Høilund-Carlsen et al. Can J Cardiol. 2007 Jun.

Abstract
in English, French

Background: According to most current guidelines, stable angina pectoris patients with a high probability of having coronary artery disease can be reliably identified clinically.

Objectives: To examine the reliability of clinical evaluation with or without an at-rest electrocardiogram (ECG) in patients with a high probability of coronary artery disease.

Patients and methods: A prospective series of 357 patients referred for coronary angiography (CA) for suspected stable angina pectoris were examined by a trained physician who judged their type of pain and Canadian Cardiovascular Society grade of pain. Pretest likelihood of disease was estimated, and all patients underwent myocardial perfusion scintigraphy (MPS) followed by CA an average of 78 days later. For analysis, the investigators focused on the approximate groups of patients with more severe disease, ie, typical angina (n=187), Canadian Cardiovascular Society grade 2 pain or higher (n=176) or high (higher than 85%) estimated pretest likelihood of disease (n=142).

Results: In the three groups, 34% to 39% of male patients and 65% to 69% of female patients had normal MPS, while 37% to 38% and 60% to 71%, respectively, had insignificant findings on CA. Of the patients who had also an abnormal at-rest ECG, 14% to 21% of men and 42% to 57% of women had normal MPS. Sex-related differences were statistically significant.

Conclusions: Clinical prediction appears to be unreliable. Addition of at-rest ECG data results in some improvement, particularly in male patients, but it makes the high probability groups so small that the addition appears to be of limited clinical relevance.

HISTORIQUE :: D’après les lignes directrices les plus récentes, il est possible de repérer avec fiabilité en clinique les patients atteints d’une angine de poitrine stable présentant une forte probabilité de coronaropathie.

OBJECTIFS :: Examiner la fiabilité de l’évaluation clinique avec ou sans électrocardiogramme (ÉCG) au repos chez les patients présentant une forte probabilité de coronaropathie.

PATIENTS ET MÉTHODOLOGIE :: Une série prospective de 357 patients aiguillés pour subir une coronarographie en raison d’une angine de poitrine présumée a été examinée par un médecin formé qui a évalué leur type de douleur et l’intensité de la douleur d’après la Société canadienne de cardiologie. On a évalué la probabilité de maladie avant l’examen, et tous les patients ont subi une scintigraphie myocardique de perfusion (SMP) suivie d’une coronarographie 78 jours plus tard, en moyenne. Pour des besoins d’analyse, les chercheurs se sont concentrés sur les groupes approximatifs de patients atteints d’une maladie plus grave, comme une angine classique (n=187), une douleur d’intensité minimale de 2 d’après la Société canadienne de cardiologie (n=176) ou une probabilité estimative élevée de maladie (supérieure à 85 %) avant l’examen (n=142).

RÉSULTATS :: Dans les trois groupes, de 34 % à 39 % des patients et de 65 % à 69 % des patientes avaient une SMP normale, tandis que de 37 % à 38 % des patients et de 60 % à 71 % des patientes, respectivement, avaient obtenu des constatations négligeables à la coronarographie. Chez les patients dont l’ÉCG au repos était également anormal, de 14 % à 21 % des hommes et de 42 % à 57 % des femmes avaient une SMP normale. Les différences selon les sexes étaient significatives d’un point de vue statistique.

CONCLUSIONS :: La prédiction clinique ne semble pas fiable. L’ajout des données de l’ÉCG au repos apporte une certaine amélioration, notamment chez les patients de sexe masculin, mais il rend les groupes à forte probabilité tellement minimes que cet ajout semble avoir une pertinence clinique limitée.

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Figures

Figure 1)
Figure 1)
A Venn diagram demonstrating the overlaps among clinical groups in patients with suspected disease (n=357). By definition, all patients with an estimated high pretest likelihood of coronary artery disease (HPL) have typical angina pectoris. Note that several patients did not belong to any of the three groups. CCS 2–3 Canadian Cardiovascular Society pain grade 2 or 3
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