Appropriate use criteria for echocardiography in the Netherlands.

INTRODUCTION: Appropriate use criteria (AUC) for echocardiography based on clinical scenarios were previously published by an American Task Force. We determined whether members of the Dutch Working Group on Echocardiography (WGE) would rate these scenarios in a similar way. METHODS: All 32 members of the WGE were invited to judge clinical scenarios independently using a blanked version of the previously published American version of AUC for echocardiography. During a face-to-face meeting, consensus about the final rating was reached by open discussion for each indication. For reasons of simplicity, the scores were reduced from a 9-point scale to a 3-point scale (indicating an appropriate, uncertain or inappropriate echo indication, respectively). RESULTS: Nine cardiologist members of the WGE reported their judgment on the echo cases (n = 153). Seventy-one indications were rated as appropriate, 35 were rated as uncertain, and 47 were rated as inappropriate. In 5% of the cases the rating was opposite to that in the original (appropriate compared with inappropriate and vice versa), whereas in 20% judgements differed by 1 level of appropriateness. After the consensus meeting, the appropriateness of 7 (5%) cases was judged differently compared with the original paper. CONCLUSIONS: Echocardiography was rated appropriate when it is applied for an initial diagnosis, a change in clinical status or a change in patient management. However, in about 5% of the listed clinical scenarios, members of the Dutch WGE rated the AUC for echocardiography differently as compared with their American counterparts. Further research is warranted to analyse this decreased external validity.

Silent versus symptomatic myocardial ischemia during exercise testing: a comparison with coronary angiographic findings.

Two-hundred-and-eighty individuals with anginal complaints, without prior myocardial infarction and with a positive exercise stress test were divided into a group (n = 67) with exercise-induced silent myocardial ischemia and another group (n = 213) with exercise-induced angina pectoris. Both underwent coronary angiography and were compared with each other with respect to various exercise and angiographic parameters. Patients with exercise-induced silent ischemia attained a longer mean exercise duration (P less than 0.001), a higher peak exercise heart rate (P less than 0.0001) and a higher peak exercise rate pressure product (P less than 0.001) than patients with exercise-induced angina pectoris. In the latter group, more patients showed exercise-induced ST-segment depression greater than 2 mm (P less than 0.05). The group of patients with silent ischemia encompassed more individuals with normal coronary arteries (P less than 0.0001). More patients with exercise-induced angina pectoris had three-vessel disease (P less than 0.0001). The exclusion of patients with normal coronary arteries (23% in those with silent ischemia group and 6% in those with exercise-induced angina had no influence on the level of significance for peak heart rate, mean exercise duration and exercise duration greater than 10 min. Thus, in this population, exercise-induced silent myocardial ischemia is associated with better exercise performance and less extensive coronary arterial pathology than in exercise-induced angina pectoris.