title: Comparative effectiveness of exercise electrocardiography with or without myocardial perfusion single photon emission computed tomography in women with suspected coronary artery disease: results from the What Is the Optimal Method for Ischemia Evaluation in Women (WOMEN) trial.
abstract: BACKGROUND
  There is a paucity of randomized trials regarding diagnostic testing in women with suspected coronary artery disease (CAD). It remains unclear whether the addition of myocardial perfusion imaging (MPI) to the standard ECG exercise treadmill test (ETT) provides incremental information to improve clinical decision making in women with suspected CAD.
  
  
  RESULTS
  We randomized symptomatic women with suspected CAD, an interpretable ECG, and ≥5 metabolic equivalents on the Duke Activity Status Index to 1 of 2 diagnostic strategies: ETT or exercise MPI. The primary end point was 2-year incidence of major adverse cardiac events, defined as CAD death or hospitalization for an acute coronary syndrome or heart failure. A total of 824 women were randomized to ETT or exercise MPI. For women randomized to ETT, ECG results were normal in 64%, indeterminate in 16%, and abnormal in 20%. By comparison, the exercise MPI results were normal in 91%, mildly abnormal in 3%, and moderate to severely abnormal in 6%. At 2 years, there was no difference in major adverse cardiac events (98.0% for ETT and 97.7% for MPI; P=0.59). Compared with ETT, index testing costs were higher for exercise MPI (P<0.001), whereas downstream procedural costs were slightly lower (P=0.0008). Overall, the cumulative diagnostic cost savings was 48% for ETT compared with exercise MPI (P<0.001).
  
  
  CONCLUSIONS
  In low-risk, exercising women, a diagnostic strategy that uses ETT versus exercise MPI yields similar 2-year posttest outcomes while providing significant diagnostic cost savings. The ETT with selective follow-up testing should be considered as the initial diagnostic strategy in symptomatic women with suspected CAD.
  
  
  BACKGROUND
  http://www.clinicaltrials.gov. Unique identifier: NCT00282711.
authors.affiliation: Emory University, Atlanta, GA 30324, USA. lshaw3@emory.edu
authors.forename: Leslee J
authors.initials: LJ
authors.lastname: Shaw
authors.forename: Jennifer H
authors.initials: JH
authors.lastname: Mieres
authors.forename: Robert H
authors.initials: RH
authors.lastname: Hendel
authors.forename: William E
authors.initials: WE
authors.lastname: Boden
authors.forename: Martha
authors.initials: M
authors.lastname: Gulati
authors.forename: Emir
authors.initials: E
authors.lastname: Veledar
authors.forename: Rory
authors.initials: R
authors.lastname: Hachamovitch
authors.forename: James A
authors.initials: JA
authors.lastname: Arrighi
authors.forename: C Noel Bairey
authors.initials: CN
authors.lastname: Merz
authors.forename: Raymond J
authors.initials: RJ
authors.lastname: Gibbons
authors.forename: Nanette K
authors.initials: NK
authors.lastname: Wenger
authors.forename: Gary V
authors.initials: GV
authors.lastname: Heller
mesh_terms: D000368:Aged; D003324:Coronary Artery Disease / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000503:physiopathology*; D004562:Electrocardiography / Q000379:methods / Q000592:standards*; D005080:Exercise Test / Q000379:methods / Q000592:standards*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000503:physiopathology; D055414:Myocardial Perfusion Imaging / Q000379:methods / Q000592:standards*; D015899:Tomography, Emission-Computed, Single-Photon / Q000379:methods / Q000592:standards*; D016896:Treatment Outcome