Use of Diagnostic Testing

Thomas Burchell, Anthony Mathur, and Peter Mills

The physician confronted with a patient with suspected cardiovascular disease has a multitude of tests available to provide diagnostic and prognostic information. Chapters 4 through 10 describe the various modalities for diagnosing cardiovascular diseases. This chapter focuses on the selection of the most appropriate tests for individual patients.

Generally, the available cardiovascular diagnostic tests can be divided into two categories: Tests that assess anatomy and tests that assess function. These categories are merging, as tests once used solely for anatomic purposes are modified to also assess function. The choice of test depends not only on the question being asked but also on the cost-effectiveness and predictive value of the test and the relative value of anatomic versus functional information. An anatomic assessment (using a test validated by comparison with coronary angiography) may be useful in some settings, but it does not eliminate the need for a functional assessment, which may be even more predictive of a patient’s prognosis and need for further intervention.

New imaging techniques must be carefully evaluated for accuracy, ability to provide the needed information, and cost-effectiveness compared with existing methods of obtaining similar information. It should be noted that the initial description of the sensitivity and specificity of a diagnostic test may overestimate what can be achieved in practice. Initial publications usually describe the assessment of a diagnostic test under rigorous conditions by experienced operators in a highly selected population. The true measure of a test is its ability to produce reliable information in a typical clinical environment.

This chapter reviews the available tests that most frequently provide diagnostic and prognostic information in the evaluation of patients with suspected cardiovascular disease. As with all diagnostic tests, the pre-test probability of disease must be considered carefully, both in choosing the most appropriate test and in its interpretation.

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