Stress Testing Can Help Rule Out Left Main Coronary Artery Disease: Study
Italy: A study published in the European Heart Journal found that standard clinical assessment combined with ECG stress testing can reliably exclude left main coronary artery disease in many patients. This simple, widely available approach may be particularly valuable in settings where CT coronary angiography is not readily accessible, helping clinicians safely identify patients at low risk while optimizing the use of advanced imaging.
The multicenter case-control study included patients with chronic coronary syndrome who underwent maximal exercise stress testing before invasive coronary angiography. Researchers compared 335 patients with left main or left main-equivalent coronary artery disease with 797 matched controls and developed a prediction model using demographic, clinical, and exercise ECG variables.
- The analysis included 335 patients with left main or left main-equivalent coronary artery disease and 797 matched controls.
- The prediction model demonstrated good diagnostic performance, with an area under the curve (AUC) of 0.78.
- Assuming a 5% prevalence of left main disease, the model achieved a negative predictive value of 98.2%.
- The approach could safely avoid invasive coronary angiography in approximately 41% of patients.
- For every 58 unnecessary angiograms avoided, only one case of left main or equivalent disease would be missed.
- The findings support an initial non-invasive management strategy for most patients with chronic coronary syndrome who are able to perform maximal exercise testing.
The researchers noted that the findings are limited to patients able to undergo a maximal, interpretable exercise stress test and may not apply to those with baseline ECG abnormalities or severe left ventricular dysfunction. They also acknowledged the retrospective design, underrepresentation of women, lack of routine intracoronary imaging, and absence of long-term prognostic validation.
Overall, the findings suggest that standard clinical assessment combined with exercise stress ECG can reliably identify patients with chronic coronary syndrome who are unlikely to have left main coronary artery disease. This approach could reduce unnecessary invasive or CT coronary angiography, optimize healthcare resources, and improve patient management, particularly in settings with limited access to advanced cardiac imaging.
De Carlo, M., Malanima, M. A., Baglietto, L., Bazan, L., Berti, S., Calabrò, P., Carmisciano, L., De Caterina, A. R., Fabozzo, S., Fornili, M., Ghisletti, A., Hellou, E., Lanza, G. A., Mancini, N., Massacesi, C., Neglia, D., Pastore, M. C., Patti, G., Tremamunno, S., . . . De Caterina, R. Standard clinical and stress electrocardiogram variables to exclude left main and left main-equivalent disease: The MASTER study. European Heart Journal. https://doi.org/10.1093/eurheartj/ehag464
