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. 2023 May 22;3(3):oead053.
doi: 10.1093/ehjopen/oead053. eCollection 2023 May.

Comparative effectiveness of exercise electrocardiography versus exercise echocardiography in women presenting with suspected coronary artery disease: a randomized study

Sothinathan Gurunathan  1   2   3 , Mayooran Shanmuganathan  1 , Ankur Chopra  1 , Jiwan Pradhan  1 , Lily Aboud  1 , Reinette Hampson  1 , Haci Yakup Yakupoglu  2 , Gabriel Bioh  1 , Ann Banfield  1 , Heather Gage  4 , Raj Khattar  2   3 , Roxy Senior  1   2   3
Affiliations

Comparative effectiveness of exercise electrocardiography versus exercise echocardiography in women presenting with suspected coronary artery disease: a randomized study

Sothinathan Gurunathan et al. Eur Heart J Open. .

Abstract

Aims: There is a paucity of randomized diagnostic studies in women with suspected coronary artery disease (CAD). This study sought to assess the relative value of exercise stress echocardiography (ESE) compared with exercise electrocardiography (Ex-ECG) in women with CAD.

Methods and results: Accordingly, 416 women with no prior CAD and intermediate probability of CAD (mean pre-test probability 41%), were randomized to undergo either Ex-ECG or ESE. The primary endpoints were the positive predictive value (PPV) for the detection of significant CAD and downstream resource utilization. The PPV of ESE and Ex-ECG were 33% and 30% (P = 0.87), respectively for the detection of CAD. There were similar clinic visits (36 vs. 29, P = 0.44) and emergency visits with chest pain (28 vs. 25, P = 0.55) in the Ex-ECG and ESE arms, respectively. At 2.9 years, cardiac events were 6 Ex-ECG vs. 3 ESE, P = 0.31. Although initial diagnosis costs were higher for ESE, more women underwent further CAD testing in the Ex-ECG arm compared to the ESE arm (37 vs. 17, P = 0.003). Overall, there was higher downstream resource utilization (hospital attendances and investigations) in the Ex-ECG arm (P = 0.002). Using National Health Service tariffs 2020/21 (British pounds) the cumulative diagnostic costs were 7.4% lower for Ex-ECG compared with ESE, but this finding is sensitive to the cost differential between ESE and Ex-ECG.

Conclusion: In intermediate-risk women who are able to exercise, Ex-ECG had similar efficacy to an ESE strategy, with higher resource utilization whilst providing cost savings.

Keywords: Coronary artery disease; Exercise electrocardiography; Randomized study; Stress echocardiography.

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Figures

Central illustration
Central illustration
Randomized controlled trial comparing diagnostic accuracy, efficacy, resource utilization, and costs based on an initial exercise echocardiography strategy vs. an exercise electrocardiography strategy in women with suspected angina.
Figure 1
Figure 1
Nomogram of the predicted exercise capacity for age in asymptomatic women.
Figure 2
Figure 2
Flow diagram of eligible and randomized patients. Women are screened from the Rapid-Access Chest Pain Clinic. *In the exercise electrocardiography arm, of the 207 patients randomized three preferred to undergo exercise stress echocardiography. Consequently, 204 underwent exercise electrocardiography and whilst 209 were randomized to the exercise stress echocardiography arm, 212 underwent exercise stress echocardiography (per protocol). **Outcome (downstream resource utilization and events) analysis was based on the final randomized patients (intention to treat). ESE, exercise stress echocardiography; Ex-ECG, exercise electrocardiography.
Figure 3
Figure 3
Index test outcome based on tests actually performed in each arm (per protocol). This demonstrates that more patients in the exercise electrocardiography arm had inconclusive tests, in comparison to the exercise stress echocardiography arm.
See this image and copyright information in PMC

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