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J Clin Invest. 1980 May; 65(5): 1210–1221.
PMCID: PMC371455

Application of conditional probability analysis to the clinical diagnosis of coronary artery disease.

Abstract

Analysis of multiple noninvasive tests offers the promise of more accurate diagnosis of coronary artery disease, but discordant test responses can occur frequently and, when observed, result in diagnostic uncertainty. Accordingly, 43 patients undergoing diagnostic coronary angiography were evaluated by noninvasive testing and the results subjected to analysis using Bayes' theorem of conditional probability. The procedures used included electrocardiographic stress testing for detection of exercise-induced ST segment depression, cardiokymographic stress testing for detection of exercise-induced precordial dyskinesis, myocardial perfusion scintigraphy for detection of exercise-induced relative regional hypoperfusion, and cardiac fluoroscopy for detection of coronary artery calcification. The probability for coronary artery disease was estimated by Bayes' theorem from each patient's age, sex, and symptom classification, and from the observed test responses. This analysis revealed a significant linear correlation between the predicted probability for coronary artery disease and the observed prevalence of angiographic disease over the entire range of probability from 0 to 100% (P less than 0.001 by linear regression). The 12 patients without angiographic disease had a mean posttest likelihood of only 7.0 +/- 2.6% despite the fact that 13 of the 60 historical and test responses were falsely "positive." In contrast, the mean posttest likelihood was 94.1 +/- 2.8% in the 31 patients with angiographic coronary artery disease, although 45 of the 155 historical and test responses were falsely "negative." In 8 of the 12 normal patients, the final posttest likelihood was under 10% and in 26 of the 31 coronary artery disease patients, it was over 90%. These estimates also correlated well with the pooled clinical judgment of five experienced cardiologists (P less than 0.001 by linear regression). The observed change in probability for disease for each of the 15 different test combinations correlated with their information content predicted according to Shannon's theorem (P less than 0.001 by linear regression). These results support the use of probability analysis in the clinical diagnosis of coronary artery disease and provide a formal basis for comparing the relative diagnostic effectiveness and cost-effectiveness of different test combinations.

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.
  • Bartel AG, Behar VS, Peter RH, Orgain ES, Kong Y. Graded exercise stress tests in angiographically documented coronary artery disease. Circulation. 1974 Feb;49(2):348–356. [PubMed]
  • Detry JM, Kapita BM, Cosyns J, Sottiaux B, Brasseur LA, Rousseau MF. Diagnostic value of history and maximal exercise electrocardiography in men and women suspected of coronary heart disease. Circulation. 1977 Nov;56(5):756–761. [PubMed]
  • Goldschlager N, Selzer A, Cohn K. Treadmill stress tests as indicators of presence and severity of coronary artery disease. Ann Intern Med. 1976 Sep;85(3):277–286. [PubMed]
  • Bartel AG, Chen JT, Peter RH, Behar VS, Kong Y, Lester RG. The significance of coronary calcification detected by fluoroscopy. A report of 360 patients. Circulation. 1974 Jun;49(6):1247–1253. [PubMed]
  • Hamby RI, Tabrah F, Wisoff BG, Hartstein ML. Coronary artery calcification: clinical implications and angiographic correlates. Am Heart J. 1974 May;87(5):565–570. [PubMed]
  • Aldrich RF, Brensike JF, Battaglini JW, Richardson JM, Loh IK, Stone NJ, Passamani ER, Ackerstein H, Seningen R, Borer JS, et al. Coronary calcifications in the detection of coronary artery disease and comparison with electrocardiographic exercise testing. Results from the National Heart, Lung, and Blood Institute's type II coronary intervention study. Circulation. 1979 Jun;59(6):1113–1124. [PubMed]
  • Vas R, Diamond GA, Wyatt HL, da Luz PL, Swan HJ, Forrester JS. Noninvasive analysis of regional myocardial wall motion: cardiokymography. Am J Physiol. 1977 Dec;233(6):H700–H706. [PubMed]
  • Diamond GA, Chag M, Vas R, Forrester JS. Cardiokymography: quantitative analysis of regional ischemic left ventricular dysfunction. Am J Cardiol. 1978 Jun;41(7):1249–1257. [PubMed]
  • Silverberg RA, Diamond GA, Vas R, Tzivoni D, Swan HJ, Forrester JS. Noninvasive diagnosis of coronary artery disease: the cardiokymographic stress test. Circulation. 1980 Mar;61(3):579–589. [PubMed]
  • Lenaers A, Block P, Thiel EV, Lebedellr M, Becquevort P, Erbsmann F, Ermans A. Segmental analysis of Ti-201 stress myocardial scintigraphy. J Nucl Med. 1977 Jun;18(6):509–516. [PubMed]
  • Turner DA, Battle WE, Deshmukh H, Colandrea MA, Snyder GJ, Fordham EW, Messer JW. The predictive value of myocardial perfusion scintigraphy after stress in patients without previous myocardial infarction. J Nucl Med. 1978 Mar;19(3):249–255. [PubMed]
  • Borer JS, Brensike JF, Redwood DR, Itscoitz SB, Passamani ER, Stone NJ, Richardson JM, Levy RI, Epstein SE. Limitations of the electrocardiographic response to exercise in predicting coronary-artery disease. N Engl J Med. 1975 Aug 21;293(8):367–371. [PubMed]
  • Erikssen J, Enge I, Forfang K, Storstein O. False positive diagnostic tests and coronary angiographic findings in 105 presumably healthy males. Circulation. 1976 Sep;54(3):371–376. [PubMed]
  • Redwood DR, Borer JS, Epstein SE. Whither the ST segment during exercise. Circulation. 1976 Nov;54(5):703–706. [PubMed]
  • Epstein SE. Value and limitations of the electrocardiographic response to exercise in the assessment of patients with coronary artery disease. Controversies in cardiology--II. Am J Cardiol. 1978 Oct;42(4):667–674. [PubMed]
  • Gorry GA, Pauker SG, Schwartz WB. The diagnostic importance of the normal finding. N Engl J Med. 1978 Mar 2;298(9):486–489. [PubMed]
  • Rifkin RD, Hood WB., Jr Bayesian analysis of electrocardiographic exercise stress testing. N Engl J Med. 1977 Sep 29;297(13):681–686. [PubMed]
  • Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med. 1979 Jun 14;300(24):1350–1358. [PubMed]
  • Enthoven AC. Shattuck Lecture--cutting cost without cutting the quality of care. N Engl J Med. 1978 Jun 1;298(22):1229–1238. [PubMed]
  • Metz CE, Goodenough DJ, Rossmann K. Evaluation of receiver operating characteristic curve data in terms of information theory, with applications in radiography. Radiology. 1973 Nov;109(2):297–303. [PubMed]
  • Okada M. A method for clinical data reduction based on "weighted entropy". IEEE Trans Biomed Eng. 1978 Sep;25(5):462–467. [PubMed]
  • McNeil BJ, Keller E, Adelstein SJ. Primer on certain elements of medical decision making. N Engl J Med. 1975 Jul 31;293(5):211–215. [PubMed]
  • Metz CE. Basic principles of ROC analysis. Semin Nucl Med. 1978 Oct;8(4):283–298. [PubMed]
  • Chaitman BR, Waters DD, Bourassa MG, Tubau JF, Wagniart P, Ferguson RJ. The importance of clinical subsets in interpreting maximal treadmill exercise test results: the role of multiple-lead ECG systems. Circulation. 1979 Mar;59(3):560–570. [PubMed]
  • Ransohoff DF, Feinstein AR. Editorial: Is decision analysis useful in clinical medicine? Yale J Biol Med. 1976 May;49(2):165–168. [PMC free article] [PubMed]
  • Hall GH. The clinical application of Bayes' theorem. Lancet. 1967 Sep 9;2(7515):555–557. [PubMed]
  • Adelstein SJ, McNeil BJ. A new diagnostic test for pulmonary embolism: how good and how costly? N Engl J Med. 1978 Aug 10;299(6):305–307. [PubMed]
  • Cohn K, Kamm B, Feteih N, Brand R, Goldschlager N. Use of treadmill score to quantify ischemic response and predict extent of coronary disease. Circulation. 1979 Feb;59(2):286–296. [PubMed]
  • Ransohoff DF, Feinstein AR. Problems of spectrum and bias in evaluating the efficacy of diagnostic tests. N Engl J Med. 1978 Oct 26;299(17):926–930. [PubMed]
  • Fryback DG. Bayes' theorem and conditional nonindependence of data in medical diagnosis. Comput Biomed Res. 1978 Oct 5;11(5):423–434. [PubMed]
  • Schwartz WB, Joskow PL. Sounding Board. Medical efficacy versus economic efficiency: a conflict in values. N Engl J Med. 1978 Dec 28;299(26):1462–1464. [PubMed]
  • Kassirer JP, Pauker SG. Should diagnostic testing be regulated? N Engl J Med. 1978 Oct 26;299(17):947–949. [PubMed]

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