title: In search of the false-negative exercise treadmill testing evidence-based use of exercise echocardiography.
abstract: BACKGROUND
  Controversy exists regarding the role of exercise treadmill testing (ETT) versus exercise stress echocardiography (ESE) as the appropriate initial noninvasive test to risk-stratify patients with chest pain. The majority of studies to date that evaluated these methodologies included patients with poor functional status and baseline electrocardiogram (ECG) abnormalities, potentially limiting the sensitivity of ETT.
  
  
  OBJECTIVE
  We examined the hypothesis that given stringent standards of exercise duration and ECG interpretability, the ETT would have a high diagnostic sensitivity for the presence of significant coronary artery disease (CAD).
  
  
  METHODS
  Results of concurrent ETT and ESE in 3,098 patients were examined, and the subset of patients with a negative ETT and positive ESE (-ETT/ + ESE) were reviewed for the presence of CAD as a function of exercise duration (< or > or = 6 min) and baseline ECG normality.
  
  
  RESULTS
  In those patients with a - ETT/ + ESE who exercised > or = 6 min, 54 had a normal baseline ECG, 22 underwent angiography and 6 had CAD (all of whom had either small, grafted or collateralized vessels). Patients with a - ETT/ + ESE who were incapable of exercising 6 min were more frequently older and female. Mortality was significantly greater in the < 6 min exercise duration group (31.4 versus 3.1%).
  
  
  CONCLUSIONS
  These findings support the use of the ETT without imaging as the initial test in patients with chest pain who have a normal baseline ECG and are able to exercise 6 min. Using these criteria, false negative findings are generally seen in patients without critical large vessel epicardial disease. The ESE should be reserved as the initial test for patients with an abnormal baseline ECG or reduced functional capacity.
authors.affiliation: Division of Cardiovascular Medicine, University of California, Davis, California 95616, USA.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Southard
authors.forename: Larry
authors.initials: L
authors.lastname: Baker
authors.forename: Saul
authors.initials: S
authors.lastname: Schaefer
mesh_terms: D006328:Cardiac Catheterization; D003327:Coronary Disease / Q000175:diagnosis* / Q000503:physiopathology; D004452:Echocardiography / Q000379:methods*; D004562:Electrocardiography; D005080:Exercise Test / Q000379:methods*; D005189:False Positive Reactions; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016276:Ventricular Function / Q000502:physiology