Exercise electrocardiography for Pre-Test Assessment of the Likelihood of Coronary Artery Disease

Laust Dupont Rasmussen, Samuel Emil Schmidt, Juhani Knuuti, David E Newby, Trisha Singh, Koen Nieman, Tjebbe W. Galema, Christiaan Vrints, Morten Bøttcher, Simon Winther

Research output: Contribution to journalArticlepeer-review

Abstract / Description of output

Objectives. To develop a tool including exercise electrocardiography (ExECG) for patient-specific clinical likelihood estimation of patients with suspected obstructive coronary artery disease (CAD).
Methods. An ExECG-weighted clinical likelihood (ExECG-CL) model was developed in a Training cohort of patients with suspected obstructive CAD undergoing ExECG. Secondly, the ExECG-CL model was applied in a CAD Validation cohort undergoing ExECG and clinically driven invasive coronary angiography and a Prognosis Validation cohort and compared to the risk factor-weighted clinical likelihood (RF-CL) model for obstructive CAD discrimination and prognostication, respectively.
In the CAD Validation cohort, obstructive CAD was defined as >50% diameter stenosis on invasive coronary angiography. For prognosis, the endpoint was non-fatal myocardial infarction and death.
Results. The Training cohort consisted of 1,214 patients (mean age 57years, 57% males). In the CAD (N=408; mean age 55years, 53% males) and Prognosis Validation (N=3,283; mean age 57years, 57% males) cohorts, 11.8% patients had obstructive CAD and 4.4% met the endpoint. In the CAD Validation cohort, discrimination of obstructive CAD was similar between the ExECG-CL and RF-CL models: area under the receiver-operating characteristic curves 83.1% (95% confidence intervals (CI) 77.5-88.7) versus 80.7% (95%CI 74.6-86.8), p=0.14. By the ExECG-CL model, more patients had very-low (≤5%) clinical likelihood of obstructive CAD compared to the RF-CL (42.2% vs. 36.0%, p<0.01) where obstructive CAD prevalence and event risk remained low.
Conclusions. ExECG incorporated into a clinical likelihood model improves re-classification of patients to a very-low clinical likelihood group with very-low prevalence of obstructive CAD and favorable prognosis.
Original languageEnglish
Early online date22 Aug 2023
Publication statusE-pub ahead of print - 22 Aug 2023

Keywords / Materials (for Non-textual outputs)

  • Coronary Artery Disease
  • chronic coronary syndrome
  • clinical likelihood
  • pre-test probability
  • exercise ECG


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