Lessons Learned From Studies of the Standard Exercise ECG Test

Motivated by recent systematic reviews of diagnostic tests for coronary artery disease (CAD) and a renewed interest in applying tests for screening healthy individuals, we felt it timely to review the lessons learned from past experience. Since the standard exercise test has been studied for some time, it provides a wealth of experience in this regard. Four major mistakes have been made when evaluating the diagnostic characteristics of the exercise test: (1) choosing subjects for test evaluation who represent a limited challenge to the diagnostic performance of the test; (2) not limiting the amount of workup bias in identifying patients for test evaluation; (3) utilizing soft end points instead of hard end points; and (4) using surrogates instead of an appropriate “gold standard.” We will step through each of these errors and provide illustrations for each. In a closing section, we will compare most of the diagnostic techniques that are available for CAD to the exercise test.