Incremental prognostic value of the exercise electrocardiogram in the initial assessment of patients with suspected angina: cohort study
Open accessAbstract
OBJECTIVE: To determine whether resting and exercise electrocardiograms (ECGs) provide prognostic value that is incremental to that obtained from the clinical history in ambulatory patients with suspected angina attending chest pain clinics. DESIGN: Multicentre cohort study. SETTING: Rapid access chest pain clinics of six hospitals in England. PARTICIPANTS: 8176 consecutive patients with suspected angina and no previous diagnosis of coronary artery disease, all of whom had a resting ECG recorded. 4848 patients with a summary exercise ECG result recorded (positive, negative, equivocal for ischaemia) comprised the summary ECG subset of whom 1422 with more detailed exercise ECG data recorded comprised the detailed ECG subset. MAIN OUTCOME MEASURE: Composite of death due to coronary heart disease or non-fatal acute coronary syndrome during median follow-up of 2.46 years. RESULTS: Receiver operating characteristics curves for the basic clinical assessment model alone and with the results of resting ECGs were superimposed with little difference in the C statistic. With the exercise ECGs the C statistic in the summary ECG subset increased from 0.70 (95% confidence interval 0.68 to 0.73) to 0.74 (0.71 to 0.76) and in the detailed ECG subset from 0.74 (0.70 to 0.79) to 0.78 (0.74 to 0.82). However, risk stratified cumulative probabilities of the primary end point at one year and six years for all three prognostic indices (clinical assessment only; clinical assessment plus resting ECG; clinical assessment plus resting ECG plus exercise ECG) showed only small differences at all time points and at all levels of risk. CONCLUSION: In ambulatory patients with suspected angina, basic clinical assessment encompasses nearly all the prognostic value of resting ECGs and most of the prognostic value of exercise ECGs. The limited incremental value of these widely applied tests emphasises the need for more effective methods of risk stratification in this group of patients.
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British investigators found a limited incremental value of the resting ECG in ambulatory patients with suspected angina, increased somewhat by adding exercise ECG data.
“Although British investigators found a limited incremental value of the resting ECG in ambulatory patients with suspected angina, increased somewhat by adding exercise ECG data, 40 several other recent investigators demonstrated prognostic value of various ECG parameters.”
From The Year of 2008 in Electrocardiology (2010) · cites this paper as [40]
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Cites
ACC/AHA 2002 Guideline Update for Exercise Testing: Summary Article
Gibbons, R. J., Balady, G. J., Bricker, J. T., CHAITMAN, B. R., Fletcher, G. F., Froelicher, V. F., Mark, D. B., McCallister, B. D., Mooss, A. N., O’Reilly, M. G., et al. (2002) · Circulation · doi:10.1161/01.cir.0000034670.06526.15 · Cited by 2,606 · see citing works
Use and Misuse of the Receiver Operating Characteristic Curve in Risk Prediction
Cook, N. R. (2007) · Circulation · doi:10.1161/circulationaha.106.672402 · Cited by 2,123 · see citing works
ACC/AHA 2002 guideline update for exercise testing: summary article
Gibbons, R. J., Balady, G. J., Bricker, J. T., CHAITMAN, B. R., Fletcher, G. F., Froelicher, V. F., Mark, D. B., McCallister, B. D., Mooss, A. N., O’Reilly, M. G., et al. (2002) · Journal of the American College of Cardiology · doi:10.1016/s0735-1097(02)02164-2 · Cited by 1,231 · see citing works
Angiotensin-converting-enzyme inhibition in stable coronary artery disease
(2004) · New England Journal of Medicine · doi:10.1056/nejmoa042739 · Cited by 1,123 · see citing works
Gibbons, R. J., Balady, G. J., Beasley, J. W., FAAFP, Bricker, J. T., Duvernoy, W. F. C., Froelicher, V. F., Mark, D. B., Marwick, T. H., McCallister, B. D., et al. (1997) · Circulation · doi:10.1161/01.cir.96.1.345 · Cited by 1,094 · see citing works
Prognostic Value of a Treadmill Exercise Score in Outpatients with Suspected Coronary Artery Disease
Mark, D. B., Shaw, L. K., Harrell, F. E., Hlatky, M. A., Lee, K. L., Bengtson, J. R., McCants, C. B., Califf, R. M., & Pryor, D. B. (1991) · New England Journal of Medicine · doi:10.1056/nejm199109193251204 · Cited by 837 · see citing works
Exercise Treadmill Score for Predicting Prognosis in Coronary Artery Disease
Mark, D. B., Hlatky, M. A., HARRELL, F. E., LEE, K. L., Califf, R. M., & PRYOR, D. B. (1987) · Annals of Internal Medicine · doi:10.7326/0003-4819-106-6-793 · Cited by 666 · see citing works
Development and Validation of a Risk Score for Predicting Death in Chagas' Heart Disease
Rassi, A., Rassi, A., Little, W. C., Xavier, S. S., Rassi, S. G., Rassi, A., Rassi, G. G., Hasslocher‐Moreno, A. M., de Sousa, A. S., & Scanavacca, M. (2006) · New England Journal of Medicine · doi:10.1056/nejmoa053241 · Cited by 647 · see citing works
Guidelines for exercise testing
Feild, M. D. J. (1986) · Journal of the American College of Cardiology · doi:10.1016/s0735-1097(86)80208-x · Cited by 527 · see citing works
Poole-Wilson, P. A., Lubsen, J., Kirwan, B.-A., van Dalen, F. J., Wagener, G., Danchin, N., Just, H., Fox, K. A., Pocock, S. J., Clayton, T. C., et al. (2004) · The Lancet · doi:10.1016/s0140-6736(04)16980-8 · Cited by 511 · see citing works
Pryor, D. B., Shaw, L., McCants, C. B., Lee, K. L., Mark, D. B., Harrell, F. E., Muhlbaier, L. H., & Califf, R. M. (1993) · Annals of Internal Medicine · doi:10.7326/0003-4819-118-2-199301150-00001 · Cited by 503 · see citing works
A clinically relevant classification of chest discomfort
Diamond, G. A. (1983) · Journal of the American College of Cardiology · doi:10.1016/s0735-1097(83)80093-x · Cited by 420 · see citing works
Jacobs, I. J., Davies, A. P., Bridges, J., et al. (1993) · BMJ · doi:10.1136/bmj.306.6884.1030 · Cited by 366 · see citing works
Incidence and Prognostic Implications of Stable Angina Pectoris Among Women and Men
Hemingway, H., McCallum, A. K., Shipley, M. J., Manderbacka, K., Martikainen, P., & Keskimäki, I. (2006) · JAMA · doi:10.1001/jama.295.12.1404 · Cited by 264 · see citing works
Self-citationMULTIMODAL APPROACH TO SCREENING FOR OVARIAN CANCER
Jacobs, I. J., Bridges, J. E., Reynolds, C., et al. (1988) · The Lancet · doi:10.1016/s0140-6736(88)90351-0 · Cited by 243 · see citing works
Daly, C., Stavola, B. L. D., Sendon, J. L. L., Tavazzi, L., Boersma, E. H., Clemens, F., Danchin, N., Delahaye, F., Gitt, A., Julian, D. G., et al. (2006) · BMJ · doi:10.1136/bmj.38695.605440.ae · Cited by 229 · see citing works
Balady, G. J., Larson, M. G., Vasan, R. S., Leip, E. P., O’Donnell, C. J., & Levy, D. A. (2004) · Circulation · doi:10.1161/01.cir.0000143226.40607.71 · Cited by 181 · see citing works
Daly, C., Clemens, F., Sendon, J. L. L., Tavazzi, L., Boersma, E. H., Danchin, N., Delahaye, F., Gitt, A. K., Julian, D. G., Mulcahy, D., et al. (2005) · European Heart Journal · doi:10.1093/eurheartj/ehi171 · Cited by 165 · see citing works
Sekhri, N., Feder, G. S., Junghans, C., Hemingway, H., & Timmis, A. D. (2007) · Heart · doi:10.1136/hrt.2006.090894 · Cited by 151 · see citing works
Pollock, S. G., Abbott, R. D., Boucher, C. A., et al. (1992) · Circulation · doi:10.1161/01.cir.85.1.237 · Cited by 149 · see citing works
Marwick, T. H., Mehta, R. H., Arheart, K. L., et al. (1997) · Journal of the American College of Cardiology · doi:10.1016/s0735-1097(97)00148-4 · Cited by 148 · see citing works
Clayton, T. C., Lubsen, J. C., Pocock, S., Vokó, Z., Kirwan, B., Fox, K. A. A., & Poole-Wilson, P. A. (2005) · BMJ · doi:10.1136/bmj.38603.656076.63 · Cited by 141 · see citing works
Uptake, yield of neoplasia, and adverse effects of flexible sigmoidoscopy screening
Atkin, W. S., Hart, A. R., Edwards, R. P., et al. (1998) · Gut · doi:10.1136/gut.42.4.560 · Cited by 140 · see citing works
Atkin, W. S., Edwards, R. P., Wardle, J., et al. (2001) · Journal of Medical Screening · doi:10.1136/jms.8.3.137 · Cited by 100 · see citing works
Decline in use of hormone therapy among postmenopausal women in the United Kingdom
Menon, U., Burnell, M., Sharma, A., Gentry‐Maharaj, A., Fraser, L. S. M., Ryan, A., Parmar, M., Hunter, M. S., & Jacobs, I. J. (2007) · Menopause The Journal of The North American Menopause Society · doi:10.1097/01.gme.0000243569.70946.9d · Cited by 55 · see citing works
Prognostic Value of the Duke Treadmill Score in Asymptomatic Women
Gulati, M., Arnsdorf, M. F., Shaw, L. J., Pandey, D. K., Thisted, R. A., Lauderdale, D. S., Wicklund, R. H., Al‐Hani, A. J., & Black, H. R. (2005) · The American Journal of Cardiology · doi:10.1016/j.amjcard.2005.03.078 · Cited by 55 · see citing works
Rywik, T. M., O’Connor, F. C., Gittings, N. S., Wright, J. G., Khan, A. A., & Fleg, J. L. (2002) · Circulation · doi:10.1161/01.cir.0000039329.47437.3b · Cited by 55 · see citing works
Confidence Intervals for Rank Statistics: Percentile Slopes, Differences, and Ratios
Newson, R. B. (2006) · The Stata Journal Promoting communications on statistics and Stata · doi:10.1177/1536867x0600600404 · Cited by 47 · see citing works
Jones, R. C., Pothier, C. E., Blackstone, E. H., & Lauer, M. S. (2004) · The American Journal of Medicine · doi:10.1016/j.amjmed.2004.06.004 · Cited by 46 · see citing works
Timmis, A., Feder, G. S., & Hemingway, H. (2006) · Heart · doi:10.1136/hrt.2006.103119 · Cited by 46 · see citing works
Self-citationShaw, L. J., Hachamovitch, R., Peterson, E. D., Lewin, H. C., Iskandrian, A. E., Miller, D. D., & Berman, D. S. (1999) · Journal of General Internal Medicine · doi:10.1046/j.1525-1497.1999.00273.x · Cited by 45 · see citing works
Poole‐Wilson, P. A., Lubsen, J. C., & Kirwan, B. (2004) · ACC Current Journal Review · doi:10.1016/j.accreview.2004.11.015 · Cited by 41 · see citing works
Bogaty, P. M., Guimond, J. V., Robitaille, N.-M., et al. (1997) · Journal of the American College of Cardiology · doi:10.1016/s0735-1097(97)00091-0 · Cited by 38 · see citing works
総合地球環境学研究所都市の地下環境に残る人間活動の影響, & 総合地球環境学研究所 (2008) · Medical Entomology and Zoology · Cited by 36 · see citing works
Pryor, D. B., Shaw, L. K., McCants, C. B., et al. (1993) · Survey of Anesthesiology · doi:10.1097/00132586-199310000-00027 · Cited by 34 · see citing works
Forslund, L. (2000) · European Heart Journal · doi:10.1053/euhj.1999.1936 · Cited by 34 · see citing works
Constant, J. (1983) · Clinical Cardiology · doi:10.1002/clc.4960060102 · Cited by 29 · see citing works
Computer-generated Correspondence for Patients Attending an Open-access Chest Pain Clinic
Ray, S., Archbold, A., Preston, S., Ranjadayalan, K., Suliman, A., & Timmis, A. (1998) · Journal of the Royal College of Physicians of London · doi:10.1016/s0035-8819(25)01820-3 · Cited by 23 · see citing works
Self-citationDiamond, G. A., & Forrester, J. S. (1982) · Circulation · doi:10.1161/01.cir.65.3.641 · Cited by 20 · see citing works
Duration and magnitude of ST-segment depression during exercise and recovery: A symmetric relation
Bogaty, P. M., Gavirelides, S., Muré, P., et al. (1995) · American Heart Journal · doi:10.1016/0002-8703(95)90313-5 · Cited by 16 · see citing works
Seminars may increase recruitment to randomised controlled trials: lessons learned from WISDOM
Paine, B. J., Stocks, N., & MacLennan, A. H. (2008) · Trials · doi:10.1186/1745-6215-9-5 · Cited by 14 · see citing works
Daly, C., Clemens, F., & Sendon, J. L. L. (2005) · ACC Current Journal Review · doi:10.1016/j.accreview.2005.08.187 · Cited by 13 · see citing works
BALADY, G. J., Larson, M. G., & Vasan, R. S. (2005) · ACC Current Journal Review · doi:10.1016/j.accreview.2004.12.126 · Cited by 12 · see citing works
Exercise testing to predict outcome in patients with angina
Hlatky, M. A. (1999) · Journal of General Internal Medicine · doi:10.1046/j.1525-1497.1999.00283.x · Cited by 9 · see citing works
Demographic Situation and Development in Nepal
Pradhanang, A. L. (1983) · Economic Journal of Nepal · doi:10.3126/ejon.v6i4.66120 · Cited by 4 · see citing works
Concluding thoughts—Looking forward
Clancy, C. M., & Lurie, N. (1999) · Journal of General Internal Medicine · doi:10.1046/j.1525-1497.1999.00268.x · Cited by 3 · see citing works
Jones, R. C., Pothier, C. E., Blackstone, E. H., et al. (2005) · ACC Current Journal Review · doi:10.1016/j.accreview.2004.12.051 · Cited by 3 · see citing works
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Research works printed but not linked: 1
- Marwick TH, Mehta R, Arheart K, Lauer MS. Use of exercise echocardiography for prognostic evaluation of patients with known or suspected coronary artery disease. J Am Coll Cardiol 1997;30:83-90.
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The Year of 2008 in Electrocardiology
Stern, S. (2010) · Annals of Noninvasive Electrocardiology · doi:10.1111/j.1542-474x.2009.00347.x · Cited by 1 · see citing works
- Authors
- Sekhri, N., Feder, G. S., Junghans, C., Eldridge, S., Umaipalan, A., Madhu, R., Hemingway, H., & Timmis, A. D.
- Affiliations
- Newham University Hospital (GB)
- University of Bristol (GB)
- University College London (GB)
- Queen Mary University of London (GB)
- Corresponding author
- Timmis, A. D
- Venue
- BMJ
- Publisher
- BMJ
- Published
- 2008-11-13
- Volume
- 337
- Issue
- nov13 2
- Pages
- a2240-a2240
- ISSN
- 0007-1447 (ISSN-L)
- 0959-8138
- 1468-5833
- PMC
- PMC2583389
- OpenAlex
- W2026794181
- Cited by
- 53
- References
- 48
- Citations by year
- 2022: 2 · 2021: 1 · 2019: 3 · 2017: 2 · 2016: 3 · 2015: 6 · 2014: 4 · 2013: 2 · 2012: 5
- FWCI
- 6.42
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- cc-by
- Locations
- BMJ (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- UCL Discovery (University College London) (submittedVersion)
- Bristol Research (University of Bristol) (submittedVersion)
- Explore Bristol Research (submittedVersion, cc-by)
- Funders
- National Institute for Health and Care Research (05/40/04)
- Topics
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Cardiac Imaging and Diagnostics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Acute Myocardial Infarction Research
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › ECG Monitoring and Analysis
- Keywords
- exercise electrocardiography, resting electrocardiogram, acute coronary syndrome, risk stratification, chest pain clinic, incremental prognostic value, medical history, coronary artery disease
- MeSH terms
- Angina Pectoris, Coronary Artery Disease, Electrocardiography, Exercise Test, Female, Humans, Male, Middle Aged, Prognosis, Sensitivity and Specificity, Cohort Studies, Proportional Hazards Models, Acute Coronary Syndrome
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