European Heart Journal Advance Access originally published online on July 2, 2007
European Heart Journal 2007 28(15):1912; doi:10.1093/eurheartj/ehm200
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Stress echocardiography compared to exercise ECG for the assessment of acute coronary syndrome: reply
Department of Cardiovascular Medicine
Northwick Park Hospital
Watford Road
Middlesex HA1 3UJ
UK
Tel: +44 208 869 2547 Fax: +44 208 864 0075 E-mail address: roxysenior{at}cardiac-research.org
We thank Drs Peteiro and Bouzas for their interest in our analysis of economic impact of stress echocardiography (SE).1 Although it is true that the number of patients undergoing coronary angiography and indeed other tests for the detection of CAD (and hence the cost) was greater in the exercise ECG (ExECG) arm compared with that of the stress echocardiography arm, it should be noted that this was because ExECG resulted in as much as 39% of the patients being classified as intermediate risk compared with only 3% in the SE group. As a result, the majority of patients in this group in the ExECG arm underwent further investigation. On the other hand, ExECG classified more patients as high risk compared with SE, but revascularization was more commonly performed in the latter group, reflecting the fact that SE was more accurate in identifying flow-limiting CAD than ExECG.2 This is also reflected in more patients after ExECG demonstrating normal coronary angiography compared with those following SE.
The study quoted by the authors that showed an apparent variance from our study consists of an entirely different population, i.e. they are all patients with established acute myocardial infarction with a high prevalence of flow-limiting CAD.3 Hence, it is not surprising that SE, which is a more sensitive test than exercise ECG for the detection of ischemia, will be more often positive than exercise ECG in this group of patients. Hence, these patients are more likely to undergo revascularization. In either scenario, SE is likely to be more cost-effective. Because of its significant superior specificity compared with ExECG, SE will be able to identify correctly the low-risk group in a low–intermediate risk population like our study demonstrated and because of its superior sensitivity, SE will correctly identify high-risk group in a population which is intermediate–high risk such as those studied by Peteiro et al.3 However, one must remember that the effectiveness of the test should take into account the life lost if flow-limiting CAD is missed. One study that took this into account did demonstrate that SE is more cost-effective than ExECG, albeit, in a chronic setting.4
References
- Jeetley P, Burden L, Stoykova B, Senior R. Clinical and economic impact of stress echocardiography compared with exercise electrocardiography in patients with acute coronary syndrome but negative troponin: a prospective randomized controlled study. Eur Heart J (2007) 28:204–211.
[Abstract/Free Full Text] - Armstrong WF, Zoghbi WA. Stress echocardiography: current methodology and clinical applications. J Am Coll Cardiol (2005) 25:1739–1747.
- Peteiro J, Monserrat, Vazquez E, Perez R, Garrido I, Vazquez N, et al. Comparison of exercise echocardiography to exercise electrocardiographic testing added to echocardiography at rest for risk stratification after uncomplicated acute myocardial infarction. Am J Cardiol (2003) 92:373–376.[CrossRef][Web of Science][Medline]
- Marwick TH, Shaw L, Case C, Vasey C, Thomas JD. Clinical and economic impact of exercise electrocardiography and exercise echocardiography in clinical practice. Eur Heart J (2003) 24:1153–1163.
[Abstract/Free Full Text]
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