title: The electrocardiographic exercise test in a population with reduced workup bias: diagnostic performance, computerized interpretation, and multivariable prediction. Veterans Affairs Cooperative Study in Health Services #016 (QUEXTA) Study Group. Quantitative Exercise Testing and Angiography.
abstract: BACKGROUND
  Empirical scores, computerized ST-segment measurements, and equations have been proposed as tools for improving the diagnostic performance of the exercise test.
  
  
  OBJECTIVE
  To compare the diagnostic utility of these scores, measurements, and equations with that of visual ST-segment measurements in patients with reduced workup bias.
  
  
  METHODS
  Prospective analysis.
  
  
  METHODS
  12 university-affiliated Veterans Affairs Medical Centers.
  
  
  METHODS
  814 consecutive patients who presented with angina pectoris and agreed to undergo both exercise testing and coronary angiography.
  
  
  METHODS
  Digital electrocardiographic recorders and angiographic calipers were used for testing at each site, and test results were sent to core laboratories.
  
  
  RESULTS
  Although 25% of patients had previously had testing, workup bias was reduced, as shown by comparison with a pilot study group. This reduction resulted in a sensitivity of 45% and a specificity of 85% for visual analysis. Computerized measurements and visual analysis had similar diagnostic power. Equations incorporating nonelectrocardiographic variables and either visual or computerized ST-segment measurement had similar discrimination and were superior to single ST-segment measurements. These equations correctly classified 5 more patients of every 100 tested (areas under the receiver-operating characteristic curve, 0.80 for equations and 0.68 for visual analysis; P < 0.001) in this population with a 50% prevalence of disease.
  
  
  CONCLUSIONS
  Standard exercise tests had lower sensitivity but higher specificity in this population with reduced work-up bias than in previous studies. Computerized ST-segment measurements were similar to visual ST-segment measurements made by cardiologists. Considering more than ST-segment measurements can enhance the diagnostic power of the exercise test.
authors.affiliation: Palo Alto Veterans Affairs Health Care System, CA 94304, USA.
authors.forename: V F
authors.initials: VF
authors.lastname: Froelicher
authors.forename: K G
authors.initials: KG
authors.lastname: Lehmann
authors.forename: R
authors.initials: R
authors.lastname: Thomas
authors.forename: S
authors.initials: S
authors.lastname: Goldman
authors.forename: D
authors.initials: D
authors.lastname: Morrison
authors.forename: R
authors.initials: R
authors.lastname: Edson
authors.forename: P
authors.initials: P
authors.lastname: Lavori
authors.forename: J
authors.initials: J
authors.lastname: Myers
authors.forename: C
authors.initials: C
authors.lastname: Dennis
authors.forename: R
authors.initials: R
authors.lastname: Shabetai
authors.forename: D
authors.initials: D
authors.lastname: Do
authors.forename: J
authors.initials: J
authors.lastname: Froning
mesh_terms: D000328:Adult; D000368:Aged; D000787:Angina Pectoris / Q000209:etiology; D015982:Bias; D017023:Coronary Angiography; D003327:Coronary Disease / Q000175:diagnosis* / Q000503:physiopathology; D004562:Electrocardiography; D005080:Exercise Test / Q000379:methods*; D006439:Hemodynamics; D006801:Humans; D007091:Image Processing, Computer-Assisted; D008875:Middle Aged; D011446:Prospective Studies; D012372:ROC Curve; D012680:Sensitivity and Specificity