Correspondence

Noninvasive Tests in Patients with Stable Coronary Artery Disease

N Engl J Med 2001; 345:1351November 1, 2001

Article

To the Editor:

In their Clinical Practice article (June 14 issue), Lee and Boucher review the use of noninvasive tests in patients with stable coronary artery disease.1 However, the authors do not comment on electron-beam computed tomography as a noninvasive diagnostic technique.

Electron-beam computed tomography is a method of cross-sectional imaging with high spatial and temporal resolution, permitting the assessment of coronary calcifications as well as the visualization of the lumina of coronary arteries. In recent years, many studies have investigated the clinical value of this type of computed tomography in patients with symptomatic or asymptomatic coronary artery disease. As a noninvasive test, electron-beam computed tomography was compared with coronary angiography and was shown to be useful in detecting coronary artery disease with high sensitivity and specificity, as long as imaging quality is adequate.2 In a study involving patients with chest pain and a low-to-intermediate risk of coronary artery disease, Raggi et al.3 compared electron-beam computed tomography as an initial testing strategy with conventional exercise testing followed by myocardial perfusion imaging. These authors showed that the use of electron-beam computed tomography offers substantial cost savings. In a study of the use of electron-beam computed tomography in the emergency department to evaluate patients who had chest pain and a normal or nondiagnostic electrocardiogram, the technique was shown to have a high degree of accuracy in distinguishing between patients at low risk for cardiac events and those at high risk.4 Electron-beam computed tomography has also been shown to predict future cardiovascular events in asymptomatic patients over a follow-up period of 3.6 years.5

Therefore, we think that electron-beam computed tomography is an evolving technique in the noninvasive evaluation of patients with coronary artery disease and that it is worth mentioning in a current review article on this topic.

Holger K. Eltzschig, M.D.
Raila Ehlers, M.D.
Harvard Medical School, Boston, MA 02115
heltzschig@partners.org

5 References

1. 1

   Lee TH, Boucher CA. Noninvasive tests in patients with stable coronary artery disease. N Engl J Med 2001;344:1840-1845
   Full Text | Web of Science | Medline

2. 2

   Achenbach S, Moshage W, Ropers D, Nossen J, Daniel WG. Value of electron-beam computed tomography for the noninvasive detection of high-grade coronary-artery stenoses and occlusions. N Engl J Med 1998;339:1964-1971
   Full Text | Web of Science | Medline

3. 3

   Raggi P, Callister TQ, Cooil B, Russo DJ, Lippolis NJ, Patterson RE. Evaluation of chest pain in patients with low to intermediate pretest probability of coronary artery disease by electron beam computed tomography. Am J Cardiol 2000;85:283-288
   CrossRef | Web of Science | Medline

4. 4

   McLaughlin VV, Balogh T, Rich S. Utility of electron beam computed tomography to stratify patients presenting to the emergency room with chest pain. Am J Cardiol 1999;84:327-328
   CrossRef | Web of Science | Medline

5. 5

   Arad Y, Spadaro LA, Goodman K, Newstein D, Guerci AD. Prediction of coronary events with electron beam computed tomography. J Am Coll Cardiol 2000;36:1253-1260
   CrossRef | Web of Science | Medline

Author/Editor Response

Dr. Lee replies:

To the Editor: Although electron-beam computed tomography is an interesting diagnostic technique, its potential effect on patients' outcomes and its appropriate clinical role remain uncertain. A consensus document published in 2000 by the American College of Cardiology and the American Heart Association includes a systematic review of the literature and concludes, “The studies demonstrate a high sensitivity of EBCT [electron-beam computed tomography] for CAD [coronary artery disease], a much lower specificity, and an overall predictive accuracy of ≈70% in typical CAD patient populations. . . . The majority of the members of the Writing Group would not recommend EBCT for diagnosing obstructive CAD because of its low specificity (high percentage of false-positive results), which can result in additional expensive and unnecessary testing to rule out a diagnosis of CAD.”1 Future research may lead to a change in this position but has not so far.

Thomas H. Lee, M.D.
Partners Community Healthcare, Boston, MA 02199

1 References

1. 1

   O'Rourke RA, Brundage BH, Froelicher VF, et al. American College of Cardiology/American Heart Association Expert Consensus document on electron-beam computed tomography for the diagnosis and prognosis of coronary artery disease. Circulation 2000;102:126-140
   Web of Science | Medline

Citing Articles (4)

Citing Articles

1. 1

   M. Nowak, P. Rosenberger, T. W. Felbinger, A. E. Götz, S. K. Shernan, K. Unertl, H. K. Eltzschig. (2006) Perioperative Echokardiographie. Der Anaesthesist 55:3, 337-361
   CrossRef

2. 2

   Matthew J Matasar, Vijaya Sundararajan, Victor R Grann, Alfred I Neugut. (2004) Management of Colorectal Cancer in Elderly Patients. Drugs & Aging 21:2, 113-133
   CrossRef

3. 3

   Thomas Seufferlein, Bernhard O Boehm. (2002) The impact of pharmacogenomics on gastrointestinal cancer therapy. Pharmacogenomics 3:5, 625-633
   CrossRef

4. 4

   (2002) Current Awareness. Pharmacoepidemiology and Drug Safety 11:3, 255-270
   CrossRef