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Abstract Objective There is a paucity of randomised diagnostic studies in women with suspected coronary artery disease(CAD). This study sought to assess the relative value of exercise stress echocardiography (ESE) compared with exercise ECG (Ex-ECG) in women with CAD. Methods Accordingly, 416 women with no prior CAD and intermediate probability of CAD (mean pre-test probability 41%), were randomized to undergo either Ex-ECG or ESE. The primary endpoints were the positive predictive value (PPV) for the detection of significant CAD and downstream resource utilisation. Results The PPV of ESE and Ex-ECG were 33% and 30% (p = 0.87) respectively for the detection of CAD. There were similar clinic visits (36 vs 29, p = 0.44) and emergency visits with chest pain (28 vs 25, p = 0.55) in the Ex-ECG and ESE arms respectively. At 2.9 years,cardiac events were 6 Ex-ECG vs 3 ESE, p = 0.31. Although initial diagnosis costs were higher for ESE, more women underwent further CAD testing in the Ex-ECG arm compared to the ESE arm (37 vs 17, p = 0.003). Overall, there was higher downstream resource utilisation (hospital attendances and investigations) in the Ex-ECG arm (p=0.002). Using National Health Service tariffs 2020/21 (British pounds) the cumulative diagnostic costs were 7.4% lower for Ex-ECG compared with ESE, but this finding is sensitive to the cost differential between ESE and Ex-ECG. Conclusion In intermediate-risk women who are able to exercise, Ex-ECG had similar efficacy to an ESE strategy, with higher resource utilisation whilst providing cost savings.

Original publication




Journal article


European Heart Journal Open


Oxford University Press (OUP)

Publication Date