Abnormal exercise electrocardiogram in an asymptomatic person — what next?

No reasonable guidelines exist for evaluating an asymptomatic individual (without evidence for ischemic heart disease on history or electrocardiography) with a positive exercise ECG. Available data indicate that persons with a strongly positive test should undergo a coronary angiography. In persons with mild to moderately positive results, cinefluoroscopy is indicated and those who show coronary calcification should have a coronary angiogram. Although stress thallium-201 is often done before coronary angiography, its role is limited. Scant data exist in women and suggest that the overall approach may not be markedly different. However, ST changes in women have a low specificity. Recent studies indicate a 95% specificity and sensitivity for positron emission tomography. Despite its high costs it may still be the most cost-effective modality by saving unwanted radionuclide studies and arteriographies.