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Khurram Nasir, MD, MPH; Rita F. Redberg, MD, MSc; Matthew J. Budoff, MD; Elaine Hui, MBBS; Wendy S. Post, MD, MS; Roger S. Blumenthal, MD

Arch Intern Med. 2004;164:1610-1620.

Accurate and safe diagnostic testing provides the crucial link between detection and optimal management of coronary artery disease (CAD). Noninvasive diagnostic testing for CAD may be less accurate in women than in men. Many noninvasive diagnostic modalities are available for this purpose. An exercise tolerance test provides an assessment of functional capacity and has the advantages of wide availability and low initial cost. However, exercise echocardiography may be the most cost-effective method for the initial assessment of coronary artery disease in intermediate-risk women owing to its higher sensitivity and specificity. Recent studies with electron-beam computed tomography reveal that women with no coronary calcification are very unlikely to have obstructive CAD. In symptomatic women with an intermediate likelihood of CAD, either an exercise treadmill test or exercise echocardiography is appropriate for initial screening and can provide useful prognostic information. Alternatively, an electron-beam computed tomographic scan with a 0 calcium score may spare many women with atypical chest pain or equivocal findings on an exercise tolerance test from undergoing more expensive stress imaging studies or coronary angiography. For high-risk symptomatic women, a more aggressive approach involving coronary angiography appears to be the preferred initial diagnostic strategy.

From the Divisions of Cardiology, Johns Hopkins Hospital, Baltimore, Md (Drs Nasir, Post, and Blumenthal), University of California San Francisco School of Medicine, San Francisco (Dr Redberg), and University of California Los Angeles School of Medicine, Los Angeles (Dr Budoff); and Guy's, King's, and St Thomas's School of Medicine, King's College, London, England (Dr Hui). The authors have no relevant financial interest in this article.

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