Noninvasive prediction of the angiographic extent of coronary artery disease after myocardial infarction: comparison of clinical, bicycle exercise electrocardiographic, and ventriculographic parameters.

Abstract

To assess alternative criteria for the prediction of multivessel coronary artery disease after myocardial infarction, we compared the clinical, bicycle electrocardiographic, and radionuclide ventriculographic (ejection fraction and wall motion) responses in 110 patients undergoing coronary angiography after myocardial infarction. Ninety-seven of the 110 patients had multivessel coronary artery disease (two or more diseased vessels). Clinical or electrocardiographic abnormalities were observed in 41 of 97 (sensitivity = 43%) patients with multivessel disease, and in only two of 13 (specificity = 85%) patients without multivessel disease. The average information content of these combined clinical and electrocardiographic variables relative to perfect discrimination was 5%. Among the scintigraphic parameters, the conventional criterion for ejection fraction abnormality, a rise of less than 5% had a sensitivity of 72% and a specificity of 62% for multivessel coronary artery disease, while a fall in ejection fraction of 5% or more had a sensitivity of 39% and specificity of 92% for multivessel coronary artery disease. The presence of an exercise wall motion abnormality in the nonadjacent noninfarcted (remote) region had a sensitivity of 82% and specificity of 55% for multivessel coronary artery disease. A more stringent criterion, worsening of remote wall motion with exercise, had a sensitivity of 52% and specificity of 75%. When this latter criterion was combined with a fall in ejection fraction, the sensitivity for multivessel coronary artery disease increased to 62%, specificity remained 75%, and information content increased from 5% to 10%. We conclude that conventional diagnostic criteria for abnormal clinical, bicycle electrocardiographic, or scintigraphic results do not identify patients with additional coronary artery disease after infarction with high accuracy. Two alternative ventriculographic parameters--a fall in ejection fraction and wall motion worsening--are similar to clinical parameters in specificity, but have a higher sensitivity and information content.