Incremental value of exercise echocardiography over exercise electrocardiography in a chest pain unit

Published:August 25, 2015DOI:


      • ExEcho provides significant incremental information over ExECG in a chest pain unit.
      • ExEcho was associated with the highest net benefit.
      • ExEcho led to the largest reduction in unnecessary coronary angiographies.



      Limited data are available on the added value of exercise echocardiography (ExEcho) over exercise electrocardiography (ExECG) in patients with suspected acute coronary syndromes (ACS) referred to a chest pain unit. We aimed to assess the incremental value of ExEcho over ExECG in this setting.


      ExECG and ExEcho were performed in parallel in 1052 patients with suspected ACS, nondiagnostic but interpretable electrocardiograms, and negative serial troponin results. The primary outcome was a composite of coronary death, nonfatal myocardial infarction or unstable angina with angiographic documentation of significant coronary artery disease within 6 months.


      The primary outcome occurred in 2/614 patients (0.3%) with both negative ExECG and ExEcho, 3/60 (5%) with positive ExECG and negative ExEcho, 73/135 (54.1%) with negative ExECG and positive ExEcho, 106/136 (77.9%) with both positive ExECG and ExEcho, and 8/107 (7.5%) with inconclusive results. The addition of ExEcho data to a model based on clinical and ExECG data significantly increased the c statistic from 0.898 to 0.968 (change +0.070, 95% confidence interval 0.052–0.092), with a continuous net reclassification improvement of 1.56 and an integrated discrimination improvement of 22% (p < 0.001). Decision curve analysis showed that a strategy of referral to coronary angiography based on ExEcho was associated with the highest net benefit and with the largest reduction in unnecessary coronary angiographies.


      ExEcho provides significant incremental prognostic information and higher net clinical benefit than a strategy based on ExECG in patients referred to a chest pain unit for suspected ACS and negative troponin levels.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to European Journal of Internal Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Niska R.
        • Bhuiya F.
        • Xu J.
        National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary.
        Natl Health Stat Rep. 2010; : 1-31
        • Lee T.H.
        • Goldman L.
        Evaluation of the patient with acute chest pain.
        N Engl J Med. 2000; 342: 1187-1195
        • Blomkalns A.L.
        • Gibler W.B.
        Chest pain unit concept: rationale and diagnostic strategies.
        Cardiol Clin. 2005; 23 ([v]): 411-421
        • Pope J.H.
        • Aufderheide T.P.
        • Ruthazer R.
        • et al.
        Missed diagnoses of acute cardiac ischemia in the emergency department.
        N Engl J Med. 2000; 342: 1163-1170
        • Brown T.W.
        • McCarthy M.L.
        • Kelen G.D.
        • Levy F.
        An epidemiologic study of closed emergency department malpractice claims in a national database of physician malpractice insurers.
        Acad Emerg Med. 2010; 17: 553-560
        • Amsterdam E.A.
        • Kirk J.D.
        • Bluemke D.A.
        • et al.
        Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association.
        Circulation. 2010; 122: 1756-1776
        • Bouzas-Mosquera A.
        • Peteiro J.
        • Alvarez-Garcia N.
        • et al.
        Prediction of mortality and major cardiac events by exercise echocardiography in patients with normal exercise electrocardiographic testing.
        J Am Coll Cardiol. 2009; 53: 1981-1990
        • Heijenbrok-Kal M.H.
        • Fleischmann K.E.
        • Hunink M.G.
        Stress echocardiography, stress single-photon-emission computed tomography and electron beam computed tomography for the assessment of coronary artery disease: a meta-analysis of diagnostic performance.
        Am Heart J. 2007; 154: 415-423
        • Diamond G.A.
        A clinically relevant classification of chest discomfort.
        J Am Coll Cardiol. 1983; 1: 574-575
        • Apple F.S.
        • Wu A.H.
        • Jaffe A.S.
        European Society of Cardiology and American College of Cardiology guidelines for redefinition of myocardial infarction: how to use existing assays clinically and for clinical trials.
        Am Heart J. 2002; 144: 981-986
        • Thygesen K.
        • Alpert J.S.
        • Jaffe A.S.
        • et al.
        Third universal definition of myocardial infarction.
        J Am Coll Cardiol. 2012; 60: 1581-1598
        • Makani H.
        • Bangalore S.
        • Halpern D.
        • Makwana H.G.
        • Chaudhry F.A.
        Cardiac outcomes with submaximal normal stress echocardiography: a meta-analysis.
        J Am Coll Cardiol. 2012; 60: 1393-1401
        • Peteiro J.
        • Bouzas-Mosquera A.
        • Broullon F.J.
        • Garcia-Campos A.
        • Pazos P.
        • Castro-Beiras A.
        Prognostic value of peak and post-exercise treadmill exercise echocardiography in patients with known or suspected coronary artery disease.
        Eur Heart J. 2010; 31: 187-195
        • Sicari R.
        • Nihoyannopoulos P.
        • Evangelista A.
        • et al.
        Stress echocardiography expert consensus statement: European Association of Echocardiography (EAE) (a registered branch of the ESC).
        Eur J Echocardiogr. 2008; 9: 415-437
        • Pencina M.J.
        • D'Agostino Sr., R.B.
        • D'Agostino Jr., R.B.
        • Vasan R.S.
        Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond.
        Stat Med. 2008; 27: 157-172
        • Pencina M.J.
        • D'Agostino Sr., R.B.
        • Steyerberg E.W.
        Extensions of net reclassification improvement calculations to measure usefulness of new biomarkers.
        Stat Med. 2011; 30: 11-21
        • Leening M.J.
        • Vedder M.M.
        • Witteman J.C.
        • Pencina M.J.
        • Steyerberg E.W.
        Net reclassification improvement: computation, interpretation, and controversies: a literature review and clinician's guide.
        Ann Intern Med. 2014; 160: 122-131
        • Pepe M.S.
        • Feng Z.
        • Huang Y.
        • et al.
        Integrating the predictiveness of a marker with its performance as a classifier.
        Am J Epidemiol. 2008; 167: 362-368
        • Vickers A.J.
        • Elkin E.B.
        Decision curve analysis: a novel method for evaluating prediction models.
        Med Decis Making. 2006; 26: 565-574
        • Steyerberg E.W.
        • Vickers A.J.
        Decision curve analysis: a discussion.
        Med Decis Making. 2008; 28: 146-149
        • Peteiro J.
        • Fabregas R.
        • Montserrat L.
        • Alvarez N.
        • Castro-Beiras A.
        Comparison of treadmill exercise echocardiography before and after exercise in the evaluation of patients with known or suspected coronary artery disease.
        J Am Soc Echocardiogr. 1999; 12: 1073-1079
        • Peteiro J.
        • Garrido I.
        • Monserrat L.
        • Aldama G.
        • Calvino R.
        • Castro-Beiras A.
        Comparison of peak and postexercise treadmill echocardiography with the use of continuous harmonic imaging acquisition.
        J Am Soc Echocardiogr. 2004; 17: 1044-1049
        • Hamm C.W.
        • Bassand J.P.
        • Agewall S.
        • et al.
        ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC).
        Eur Heart J. 2011; 32: 2999-3054
        • Anderson J.L.
        • Adams C.D.
        • Antman E.M.
        • et al.
        2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
        J Am Coll Cardiol. 2013; 61: e179-e347
        • Jeetley P.
        • Burden L.
        • Stoykova B.
        • Senior R.
        Clinical and economic impact of stress echocardiography compared with exercise electrocardiography in patients with suspected acute coronary syndrome but negative troponin: a prospective randomized controlled study.
        Eur Heart J. 2007; 28: 204-211
        • Shah B.N.
        • Balaji G.
        • Alhajiri A.
        • Ramzy I.S.
        • Ahmadvazir S.
        • Senior R.
        Incremental diagnostic and prognostic value of contemporary stress echocardiography in a chest pain unit: mortality and morbidity outcomes from a real-world setting.
        Circ Cardiovasc Imaging. 2013; 6: 202-209
        • Bedetti G.
        • Pasanisi E.M.
        • Tintori G.
        • et al.
        Stress echo in chest pain unit: the SPEED trial.
        Int J Cardiol. 2005; 102: 461-467
        • Peteiro J.
        • Bouzas-Mosquera A.
        • Broullon F.
        • Martinez D.
        • Yanez J.
        • Castro-Beiras A.
        Value of an exercise workload ≥10 metabolic equivalents for predicting inducible myocardial ischemia.
        Circ Cardiovasc Imaging. 2013; 6: 899-907
        • Pellikka P.A.
        • Nagueh S.F.
        • Elhendy A.A.
        • Kuehl C.A.
        • Sawada S.G.
        American Society of Echocardiography recommendations for performance, interpretation, and application of stress echocardiography.
        J Am Soc Echocardiogr. 2007; 20: 1021-1041
        • Maganti K.
        • Rigolin V.H.
        Stress echocardiography versus myocardial SPECT for risk stratification of patients with coronary artery disease.
        Curr Opin Cardiol. 2003; 18: 486-493