FREE NEJM E-TOC    HOME   |   SUBSCRIBE   |   CURRENT ISSUE   |   PAST ISSUES   |   COLLECTIONS   |   Search Term  Advanced Search

Sign in | Get NEJM's E-Mail Table of Contents — Free | Subscribe

Previous Volume 309:518-522 September 1, 1983 Number 9 Next

	Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited PubMed Citation

Abstract

Although exercise radionuclide ventriculography was initially reported to be a highly specific test for coronary-artery disease, later studies reported a high false-positive rate. To verify this turnabout, we analyzed the responses in 77 angiographically normal patients; 32 were studied from 1978 to 1979 (the early period), and 45 from 1980 to 1982 (the recent period). Most patients studied in the early period had normal responses (94 per cent for ejection fraction and 84 per cent for wall motion). In contrast, normal responses were less frequent in patients studied in the recent period (49 per cent for ejection fraction and 36 per cent for wall motion, P less than 0.001). The probability of coronary disease before testing was higher in these patients (38 vs. 7 per cent, P less than 0.001). More patients studied in the recent period underwent radionuclide ventriculography before angiography (78 vs. 22 per cent, P less than 0.001), and more of these prior studies had abnormal results than those performed after angiography (55 vs. 6 per cent, P less than 0.0001). Thus, two factors are responsible for the temporal decline in specificity: a change in the population being tested (pretest referral bias) and a preferential selection of patients with a positive test response for coronary angiography (post-test referral bias).

This article has been cited by other articles:

• Sampson, U. K., Dorbala, S., Limaye, A., Kwong, R., Di Carli, M. F. (2007). Diagnostic Accuracy of Rubidium-82 Myocardial Perfusion Imaging With Hybrid Positron Emission Tomography/Computed Tomography in the Detection of Coronary Artery Disease. J Am Coll Cardiol 49: 1052-1058 [Abstract] [Full Text]  
• Klem, I., Heitner, J. F., Shah, D. J., Sketch, M. H. Jr, Behar, V., Weinsaft, J., Cawley, P., Parker, M., Elliott, M., Judd, R. M., Kim, R. J. (2006). Improved Detection of Coronary Artery Disease by Stress Perfusion Cardiovascular Magnetic Resonance With the Use of Delayed Enhancement Infarction Imaging. J Am Coll Cardiol 47: 1630-1638 [Abstract] [Full Text]  
• Abidov, A., Rozanski, A., Hachamovitch, R., Hayes, S. W., Aboul-Enein, F., Cohen, I., Friedman, J. D., Germano, G., Berman, D. S. (2005). Prognostic significance of dyspnea in patients referred for cardiac stress testing.. NEJM 353: 1889-1898 [Abstract] [Full Text]  
• Christian, T. F. (2005). Anatomy of an Emerging Diagnostic Test: Computed Tomographic Coronary Angiography. Circulation 112: 2222-2225 [Full Text]  
• Hayashino, Y., Goto, M., Noguchi, Y., Fukui, T. (2005). Ventilation-Perfusion Scanning and Helical CT in Suspected Pulmonary Embolism: Meta-Analysis of Diagnostic Performance. Radiology 234: 740-748 [Abstract] [Full Text]  
• Mieres, J. H., Shaw, L. J., Arai, A., Budoff, M. J., Flamm, S. D., Hundley, W. G., Marwick, T. H., Mosca, L., Patel, A. R., Quinones, M. A., Redberg, R. F., Taubert, K. A., Taylor, A. J., Thomas, G. S., Wenger, N. K. (2005). Role of Noninvasive Testing in the Clinical Evaluation of Women With Suspected Coronary Artery Disease: Consensus Statement From the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association. Circulation 111: 682-696 [Abstract] [Full Text]  
• Blackstone, E. H., Lauer, M. S. (2004). Caveat emptor: The treachery of work-up bias. J. Thorac. Cardiovasc. Surg. 128: 341-344 [Full Text]  
• Berman, D. S., Wong, N. D., Gransar, H., Miranda-Peats, R., Dahlbeck, J., Hayes, S. W., Friedman, J. D., Kang, X., Polk, D., Hachamovitch, R., Shaw, L., Rozanski, A. (2004). Relationship between stress-induced myocardial ischemia and atherosclerosis measured by coronary calcium tomography. J Am Coll Cardiol 44: 923-930 [Abstract] [Full Text]  
• Whiting, P., Rutjes, A. W.S., Reitsma, J. B., Glas, A. S., Bossuyt, P. M.M., Kleijnen, J. (2004). Sources of Variation and Bias in Studies of Diagnostic Accuracy: A Systematic Review. ANN INTERN MED 140: 189-202 [Abstract] [Full Text]  
• Peteiro, J, Monserrat, L, Perez, R, Vazquez, E, Vazquez, J.M, Castro-Beiras, A (2003). Accuracy of peak treadmill exercise echocardiography to detect multivessel coronary artery disease: comparison with post-exercise echocardiography. Eur J Echocardiogr 4: 182-190 [Abstract] [Full Text]  
• Feinstein, A R (2002). Misguided efforts and future challenges for research on "diagnostic tests". J. Epidemiol. Community Health 56: 330-332 [Abstract] [Full Text]  
• Irwig, L., Bossuyt, P., Glasziou, P., Gatsonis, C., Lijmer, J. (2002). Evidence base of clinical diagnosis: Designing studies to ensure that estimates of test accuracy are transferable. BMJ 324: 669-671 [Full Text]  
• Williams, S. V., Fihn, S. D., Gibbons, R. J. (2001). Guidelines for the Management of Patients with Chronic Stable Angina: Diagnosis and Risk Stratification. ANN INTERN MED 135: 530-547 [Abstract] [Full Text]  
• Garcia, E. V., Cooke, C. D., Folks, R. D., Santana, C. A., Krawczynska, E. G., De Braal, L., Ezquerra, N. F. (2001). Diagnostic Performance of an Expert System for the Interpretation of Myocardial Perfusion SPECT Studies. JNM 42: 1185-1191 [Abstract] [Full Text]  
• Wallis, J. W. (2001). Use of Artificial Intelligence in Cardiac Imaging. JNM 42: 1192-1194 [Full Text]  
• Shavelle, D. M., Budoff, M. J., LaMont, D. H., Shavelle, R. M., Kennedy, J. M., Brundage, B. H. (2000). Exercise testing and electron beam computed tomography in the evaluation of coronary artery disease. J Am Coll Cardiol 36: 32-38 [Abstract] [Full Text]  
• Schmermund, A., Denktas, A. E., Rumberger, J. A., Christian, T. F., Sheedy, P. F. II, Bailey, K. R., Schwartz, R. S. (1999). Independent and incremental value of coronary artery calcium for predicting the extent of angiographic coronary artery disease: Comparison with cardiac risk factors and radionuclide perfusion imaging. J Am Coll Cardiol 34: 777-786 [Abstract] [Full Text]  
• Gibbons, R. J., Chatterjee, K., Daley, J., Douglas, J. S., Fihn, S. D., Gardin, J. M., Grunwald, M. A., Levy, D., Lytle, B. W., O'Rourke, R. A., Schafer, W. P., Williams, S. V., Ritchie, J. L., Gibbons, R. J., Cheitlin, M. D., Eagle, K. A., Gardner, T. J., Garson, A. Jr, Russell, R. O., Ryan, T. J., Smith, S. C. Jr (1999). ACC/AHA/ACP-ASIM guidelines 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). J Am Coll Cardiol 33: 2092-2197 [Full Text]  
• Yang, P. C., Kerr, A. B., Liu, A. C., Liang, D. H., Hardy, C., Meyer, C. H., Macovski, A., Pauly, J. M., Hu, B. S. (1998). New real-time interactive cardiac magnetic resonance imaging system complements echocardiography. J Am Coll Cardiol 32: 2049-2056 [Abstract] [Full Text]  
• Fleischmann, K. E., Hunink, M. G. M., Kuntz, K. M., Douglas, P. S. (1998). Exercise Echocardiography or Exercise SPECT Imaging?: A Meta-analysis of Diagnostic Test Performance. JAMA 280: 913-920 [Abstract] [Full Text]  
• Douglas, P. S. (1997). Is Noninvasive Testing for Coronary Artery Disease Accurate?. Circulation 95: 299-302 [Full Text]  
• Roger, V. L., Pellikka, P. A., Bell, M. R., Chow, C. W.H., Bailey, K. R., Seward, J. B (1997). Sex and Test Verification Bias: Impact on the Diagnostic Value of Exercise Echocardiography. Circulation 95: 405-410 [Abstract] [Full Text]  
• Okin, P. M., Kligfield, P. (1995). Gender-Specific Criteria and Performance of the Exercise Electrocardiogram. Circulation 92: 1209-1216 [Abstract] [Full Text]  
• Zaret, B. L., Rigo, P., Wackers, F. J.T., Hendel, R. C., Braat, S. H., Iskandrian, A. S., Sridhara, B. S., Jain, D., Itti, R., Serafini, A. N., Goris, M. L., Lahiri, A. (1995). Myocardial Perfusion Imaging With 99mTc Tetrofosmin : Comparison to 201Tl Imaging and Coronary Angiography in a Phase III Multicenter Trial. Circulation 91: 313-319 [Abstract] [Full Text]  
• Van Der Schouw, Y. T., Straatman, H., Verbeek, A. L.M. (1994). ROC Curves and the Areas under Them for Dichotomized Tests: Empirical Findings for Logistically and Normally Distributed Diagnostic Test Results. Med Decis Making 14: 374-381 [Abstract]  
• Zaret, B. L., Wackers, F. J. (1993). Nuclear Cardiology- First of Two Parts. NEJM 329: 775-783 [Full Text]  
• Sacher, H. L., Sacher, M. L., Landau, S. W., Dietrich, K. A., Chien, A., Dooley, F. (1992). First-Pass Radionuclide Cineangiography: A Reevaluation of Its Sensitivity and Limitations in the Detection of Significant Coronary Artery Disease. ANGIOLOGY 43: 470-476 [Abstract]  
• Diamond, G. A. (1992). What Is the Effect of Sampling Error on ROC Analysis in the Face of Verification Bias?. Med Decis Making 12: 155-156  
• Diamond, G. A. (1992). Off Bayes: Effect of Verification Bias on Posterior Probabilities Calculated Using Bayes' Theorem. Med Decis Making 12: 22-30 [Abstract]  
• Jensen, F. T., Lund, O., Erlandsen, M. (1991). Reliability of Three Computer Methods in the Analysis of ECG-Gated Radionuclide Left Ventriculography: Interrecording, Interobserver and Intraobserver Variability. ANGIOLOGY 42: 866-877 [Abstract]  
• Diamond, G. A. (1991). Affirmative Actions: Can the Discriminant Accuracy of a Test Be Determined in the Face of Selection Bias?. Med Decis Making 11: 48-56 [Abstract]  
• Diamond, G. A. (1987). ROC Steady: A Receiver Operating Characteristic Curve That Is Invariant Relative to Selection Bias. Med Decis Making 7: 238-243 [Abstract]  
• Simel, D. L., Feussner, J. R., Delong, E. R., Matchar, D. B. (1987). Intermediate, Indeterminate, and Uninterpretable Diagnostic Test Results. Med Decis Making 7: 107-114 [Abstract]