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Articles: Michael S. Lauer, Claire E. Pothier, David J. Magid, S. Scott Smith, and Michael W. Kattan An Externally Validated Model for Predicting Long-Term Survival after Exercise Treadmill Testing in Patients with Suspected Coronary Artery Disease and a Normal Electrocardiogram Ann Intern Med 2007; 147: 821-828 [Abstract] [Full text] [PDF]

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Did treatment of positive tests obscure prediction?

D. Scott Grubbs   (30 January 2008)

In Defense of the Value of the History Taken from Patients with Chest Pain

William H Carter, MD, FACC   (18 January 2008)

Did treatment of positive tests obscure prediction? 30 January 2008
D. Scott Grubbs, MD St. Francis Hospital System Send rapid response to journal: Re: Did treatment of positive tests obscure prediction? sgrubbs{at}stfrancishealth.org D. Scott Grubbs	Dr. Lauer, et al have published a very intriguing study, which seems to corroborate others in many respects. I wonder, however, if the fact that ST segment changes and anginal symptoms during the test have negative correlation might indicate something else. There is no indication that I can find that this was simply an observational study, with the subjects sent home to usual care regardless of the test findings. I suspect that those patients who demonstrated those classically positive changes went on to catheterization and other interventions and therefore avoided cardiac events that would have otherwise caused a positive correlation. Absent assurance that this was not the case, I would be very hesitant to employ the nomogram (as least pertaining to ST and Angina) the next time I encounter them doing a stress test. Conflict of Interest: None declared
In Defense of the Value of the History Taken from Patients with Chest Pain 18 January 2008
William H Carter, MD, FACC, MD West Virginia University, Charleston Division Send rapid response to journal: Re: In Defense of the Value of the History Taken from Patients with Chest Pain wcarter{at}hsc.wvu.edu William H Carter, MD, FACC	The excellent article by Lauer evaluating clinical predictors of survival after stress testing further refines the predictive value of exercise treadmill testing beyond that of the valuable Duke Treadmill Score.1 However, we are concerned that some readers will assume that a history of typical angina has no clinical value, an assumption we doubt Lauer et al meant to imply. The study found no correlation with the history of typical angina versus other types of chest pain with the future survival. The authors correctly noted prior conflicting studies including a report by many of the same authors of the above report.2 A typical history of angina depends on how the history is taken. Open ended questions are known to lead to more valid conclusions compared to leading questions.3 The questions in the current study were all leading questions versus open ended questions. “Is the pain or discomfort substernal?” vs. “Where is the pain?”. “Is the pain or discomfort brought on by physical activity or emotional stress?” vs. “What causes the pain?”, etc. Would the findings of the prognostic value of the history been different had open ended questions been asked? The Diamond/Forrester study and the combined CASS and Duke Database all demonstrate the strong predictive value of the history in predicting the presence of coronary disease, (versus all cause mortality at five years), and have been incorporated. Thus we should keep in perspective the findings of this study considering the (1) methodology of taking the chest pain history and (2) the totality of prior evidence supporting the clinical value of the history in the chest pain patientsepeatedly in stress testing guidelines.4 1. Lauer MS,. Pothier CE, Magid DJ, MD, Smith SS, Kattan MW, An Externally Validated Model for Predicting Long-Term Survival after Exercise Treadmill Testing in Patients with Suspected Coronary Artery Disease and a Normal Electrocardiogram. Ann Internal medicine: 2007, 147:821-828 2. Jones RC, Pothier CE, Blackstone EH, Lauer MS,: Prognostic Importance of Presenting Symptoms in Patients Undergoing Exercise Testing for Evaluation of Known or Suspected Coronary Disease., Am J Med. 2004;117:380 –389. 3. Roter, DL Physicians Interviewing Styles and Medical Information Obtained from Patients. Journal of General Internal Medicine; Vol. 2, 1987:325-329. 4. ACC/AHA 2002 Guideline Update for the Management of Patients with Chronic Stable Angina: J Am Coll Cardiol, 2003; 41: 159-68 (full text of guidelines www.acc.org pg 13)