CASE SCENARIO

Performance x Utilityof complementary exams for the diagnosis of coronary artery disease

It has been observedby the managers ofoutpatient facilitiesthat chest pain investigation is madein different waysand variesaccording tothe solicitant professional, frequentlyinvolvingthe requestofCTcoronaryangiography. Managerswant tomakechest pain investigationmore uniform among practitioners by establishingcriteria for each of the test that are available.

Performance Question

P Symptomatic patients with suspicious coronary artery disease

I Multislice CT coronary angiography, Treadmill Test, SPECT, Stress Echocardiogram

CCoronariography

OAccuracy of each individual test

Utility Question

P Symptomatic patients with suspicious coronary artery disease

I1Multislice CT coronary angiography

I2SPECT

I3Stress Echocardiogram

CTreadmill Test

OUtility of the different strategies related to the use of treadmill test to investigate coronary artery disease before indicating a coronariography

Search Strategy

Type of study: Guidelines
Source: Pubmed

Method / Search strategy / Results
Search combined by Mesh terms and text words directed for the title and abstract of the paper / ("Angina Pectoris"[Mesh] AND ("Guideline"[Publication Type] OR "Guidelines as Topic"[Mesh])) and "chronic"[Title/Abstract] and "stable"[Title/Abstract] / 41
("Angina Pectoris"[Mesh] or (("Angina”[Title/Abstract] or "chest pain"[Title/Abstract]) AND (“chronic”[Title/Abstract] OR "stable"[Title/Abstract]))) AND ("Guideline"[Publication Type] OR "Guidelines as Topic"[Mesh] OR “Guideline”[Title/Abstract] or “Guidelines”[Title/Abstract]) AND “Tomography”[Title/Abstract] / 26

Best evidence found: ACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina).

Type of study: Systematic Review
Source: Clinical Queries on Pubmed

Method / Search strategy / Results
Search by text words directed for the title and abstract of the paper / ("coronary angiography"[Title/Abstract] and "tomography"[Title/Abstract]) / 53

Best evidence found: G Mowatt, E Cummins, N Waugh, S Walker, J Cook, X Jia, GS Hillis and C Fraser. Systematic review of the clinical effectiveness and cost-effectiveness of 64-slice or higher computed tomography angiography as an alternative to invasive coronary angiography in the investigation of coronary artery disease. Health Technology Assessment 2008.

Results

Pre-test probability of disease by sex and age according to Duke criteria, in patients with normal rest ECG (table 10in the guideline).

Eachvalue represents the % of people withsignificant coronarydisease. The first valuerefers tolow-risk patients, middle age, no historyof diabetes, smoking, or dyslipidemia.The second valuerefers tomoderate to high riskpatients characterizedby the presenceof at leastonerisk factor.

Performance of the tests

Test / Author, year / Sex / Sens / Spec / LR(T+) / LR(T-)
Teste de Esforço / Morise and Diamond, 1995 / M / 0,40
(0,34-0,46) / 0,96
(0,94-0,98) / 10,00
(5,67-23) / 0,63
(0,55-0,70)
W / 0,33
(0,25-0,41) / 0,89
(0,85-0,93) / 3,00
(1,67-5,86) / 0,75
(0,63-0,88)
SPECT / Santana Boado, 1998 / M / 0,93
(0,87-0,98) / 0,89
(0,67-0,99) / 8,45
(2,64-98) / 0,08
(0,02-0,19)
W / 0,85
(0,62-0,97) / 0,91
(0,78-0,97) / 9,44
(2,82-32,33) / 0,16
(0,03-0,49)
Eco de Stress / Roger, 1997 / M / 0,42
(0,38-0,49) / 0,83
(0,77-0,87) / 2,47
(1,65-3,77) / 0,70
(0,59-0,81)
W / 0,32
(0,25-0,40) / 0,86
(0,82-0,89) / 2,29
(1,39-3,64) / 0,79
(0,67-0,91)
Calcium score / Budoff, 2002 / T / 0,95 / 0,66 / 2,79 / 0,08
Multislice CTCoronary / Mowat, 2008 / T / 0,96
(0,95-0,99) / 0,87
(0,85-0,91) / 7,38
(5,28-11) / 0,05
(0,01-0,06)

Sens: Sensitivity; Spec: Specificity; LR(T+): LR when the result of the test is positive[Sens/(1-Spec)]; LR(T-): LR when the result of the test is negative [(1-Sens)/Spec].

Harm due to cancer

Tests / Author, year / Radiation dosis / N necessary to cause 1 cancer* / Effectiveness†
Treadmil Test / 0 / -
SPECT / Smith-Bindman, 2009 / 9.2 a 14.8 mSv / ♀150 – 420
♂390 – 790
Stress Echo / 0 / -
Calcium Score / Smith-Bindman, 2009 / 0.8 a 10.5 mSv / ♀390 – 1090§
♂1040 – 2080§
Multislice CT Coronárias / Smith-Bindman, 2009 / 10 a 15 mSv / ♀150 – 420
♂390 – 790

* Risk of cancerduring lifetime attributable to one single exposure.

♂Cancer in thorax region in young (20 years) and old (60 years) man.

♀Breast cancer in in young (20 years) and old (60 years) woman.

§Estimated from thorax CT without contrast.

† No randomized controlled trial was found.

1

This material was developed for academic purposes only, thus, should not be used as support for decision making.