title: Relative clinical and economic impact of exercise echocardiography vs. exercise electrocardiography, as first line investigation in patients without known coronary artery disease and new stable angina: a randomized prospective study.
abstract: Exercise electrocardiography (ExECG) is widely used in suspected stable angina (SA) as the initial test for the evaluation of coronary artery disease (CAD). We hypothesized that exercise stress echo (ESE) would be efficacious with cost advantage over ExECG when utilized as the initial test.
  
  
  
  Consecutive patients with suspected SA, without known CAD were randomized into ExECG or ESE. Patients with positive tests were offered coronary angiography (CA) and with inconclusive tests were referred for further investigations. All patients were followed-up for cardiac events (death, myocardial infarction, and unplanned revascularization). Cost to diagnosis of CAD was calculated by adding the cost of all investigations, up to and including CA. In the 194 and 191 patients in the ExECG vs. ESE groups, respectively, pre-test probability of CAD was similar (34 ± 23 vs. 35 ± 25%, P = 0.6). Results of ExECG were: 108 (55.7%) negative, 14 (7.2%) positive, 72 (37.1%) inconclusive and of ESE were 181 (94.8%) negative, 9 (4.7%) positive, 1 (0.5%) inconclusive, respectively. Patients with obstructive CAD following positive ESE vs. Ex ECG were 9/9 vs. 9/14, respectively (P = 0.04). Cost to diagnosis of CAD was £266 for ESE vs. £327 for ExECG (P = 0.005). Over a mean follow-up period of 21 ± 5 months, event rates were similar between the two groups.
  
  
  
  In this first randomized study, ESE was more efficacious and demonstrated superior cost-saving, compared with ExECG when used as the initial investigation for the evaluation of CAD in patients with new-onset suspected SA without known CAD.
authors.affiliation: Department of Cardiovascular Medicine and Institute for Medical Research, Northwick Park Hospital, Harrow, UK.|Centre for Health Informatics and Multi-Professional Education, University College London, London, UK.
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Zacharias
authors.affiliation: Department of Cardiovascular Medicine and Institute for Medical Research, Northwick Park Hospital, Harrow, UK.
authors.forename: Asrar
authors.initials: A
authors.lastname: Ahmed
authors.affiliation: Department of Cardiovascular Medicine and Institute for Medical Research, Northwick Park Hospital, Harrow, UK.
authors.forename: Benoy N
authors.initials: BN
authors.lastname: Shah
authors.affiliation: Department of Cardiovascular Medicine and Institute for Medical Research, Northwick Park Hospital, Harrow, UK.
authors.forename: Sothinathan
authors.initials: S
authors.lastname: Gurunathan
authors.affiliation: Department of Cardiovascular Medicine and Institute for Medical Research, Northwick Park Hospital, Harrow, UK.
authors.forename: Grace
authors.initials: G
authors.lastname: Young
authors.affiliation: Centre for Health Informatics and Multi-Professional Education, University College London, London, UK.
authors.forename: Dionisio
authors.initials: D
authors.lastname: Acosta
authors.affiliation: Department of Cardiovascular Medicine and Institute for Medical Research, Northwick Park Hospital, Harrow, UK roxysenior@cardiac-research.org.|Cardiovascular, Biomedical Research Unit, Department of Cardiology, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.|Department of Cardiology, Imperial College London, London, UK.
authors.forename: Roxy
authors.initials: R
authors.lastname: Senior
mesh_terms: D000328:Adult; D000368:Aged; D060050:Angina, Stable / Q000175:diagnosis*; D003324:Coronary Artery Disease / Q000175:diagnosis; D023921:Coronary Stenosis / Q000000981:diagnostic imaging* / Q000503:physiopathology; D003362:Cost-Benefit Analysis; D003937:Diagnosis, Differential; D025401:Echocardiography, Stress / Q000191:economics* / Q000379:methods; D004562:Electrocardiography; D005080:Exercise Test / Q000191:economics* / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D018570:Risk Assessment; D012680:Sensitivity and Specificity
keywords: cost; efficacy; exercise echocardiography; exercise electrocardiography; stable angina