HomeCirculationVol. 123, No. 23Response to Letter Regarding Article, “Selecting a Noninvasive Imaging Study After an Inconclusive Exercise Test” Free AccessReplyPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReplyPDF/EPUBResponse to Letter Regarding Article, “Selecting a Noninvasive Imaging Study After an Inconclusive Exercise Test” Ron Blankstein and Adam D. DeVore Ron BlanksteinRon Blankstein Noninvasive Cardiovascular Imaging Program Departments of Medicine (Cardiovascular Division) and Radiology Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston, MA (Blankstein, DeVore) Search for more papers by this author and Adam D. DeVoreAdam D. DeVore Noninvasive Cardiovascular Imaging Program Departments of Medicine (Cardiovascular Division) and Radiology Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston, MA (Blankstein, DeVore) Search for more papers by this author Originally published14 Jun 2011https://doi.org/10.1161/CIRCULATIONAHA.110.017632Circulation. 2011;123:e633We thank Schuster et al for their interest in our clinician update article,1 and for their thoughtful comments. We believe that many low-risk patients who are able to exercise and have a normal baseline ECG can be effectively evaluated with exercise treadmill testing. In our institution, despite the availability of many advanced imaging modalities, exercise treadmill testing remains the most commonly performed initial test for this patient population, an approach that is also supported by current guidelines.2,3 Although we certainly agree that the diagnostic accuracy of ECG changes to detect ischemia is lower than other noninvasive techniques, it is important to note that there are other important data provided by this test such as functional capacity and exercise-induced symptoms. Notably, patients that can achieve ≥10 metabolic equivalents are extremely unlikely to have any ischemia and have an excellent prognosis.4With respect to choosing between anatomic and functional imaging tests, it is important to understand that, in many cases, these techniques offer complementary data,5 and that the initial choice of test relies on the patient's pretest probability of obstructive disease. However, it would be oversimplified, and therefore inaccurate, to state that all patients with an intermediate pretest probability of coronary artery disease should have a functional test. The category of intermediate-risk patients represents a very large and diverse group of patients, most of whom do not have obstructive coronary artery disease, and would thus have a negative functional test.6 Therefore, a test that will identify the presence or absence of coronary artery disease could be more likely to influence subsequent pharmacological and lifestyle therapies.We strongly agree that functional testing—whether performed by invasive or noninvasive techniques—should guide the decision regarding coronary revascularization. However, many patients referred for noninvasive imaging have no or only mild abnormalities. In these patients, the role and intensity of medical therapy could be influenced by the presence, extent, and severity of coronary artery disease. However, in higher-risk patients, or those who have known coronary artery disease, functional testing for ischemia will be most beneficial, because it can identify the potential benefit from coronary revascularization. Pertinent to the discussion of risk assessment, it is worthwhile pointing out that, in the case presented in our update, the patient had already undergone an exercise treadmill testing and did not have any high-risk features. The reassuring results of this test can therefore be used to modify the pretest probability before subsequent testing (ie, lower the likelihood of obstructive disease).In conclusion, we believe that further studies are needed to better identify which intermediate-risk patients are more likely to have obstructive disease (and therefore should be referred for functional imaging) versus which ones may benefit from initial testing with computed tomography angiography. It must also be recognized that risk prediction models are based on population-level studies, and therefore physicians—who must make decisions about individual patients—must incorporate their clinical judgment and patient preferences and comorbidities, as well, when selecting the most optimal test.Ron Blankstein, MDAdam D. DeVore, MD Noninvasive Cardiovascular Imaging Program Departments of Medicine (Cardiovascular Division) and Radiology Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston, MADisclosuresNone.
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Jan 2, 2023
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