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Alternative Referent Standards for Cardiac Normality: Implications for Diagnostic Testing

ALAN ROZANSKI, M.D.; GEORGE A. DIAMOND, M.D.; JAMES S. FORRESTER, M.D.; DANIEL S. BERMAN, M.D.; DENISE MORRIS, B.S.; and H. J. C. SWAN, M.D., Ph.D.
[+] Article and Author Information

Grant support: in part by Specialized Center of Research Grant 17651 from the National Institutes of Health, and a Grant-in-Aid to Dr. Rozanski from the American Heart Association, Greater Los Angeles Affiliate, Inc.

▸Requests for reprints should be addressed to Alan Rozanski, M.D.; Division of Cardiology, Cedars-Sinai Medical Center, 8700 Beverly Boulevard; Los Angeles, CA 90048.


Los Angeles, California


©1984 American College of PhysiciansAmerican College of Physicians


Ann Intern Med. 1984;101(2):164-171. doi:10.7326/0003-4819-101-2-164
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The radionuclide ventriculographic exercise response was evaluated in three patient populations representing alternative referent standards for cardiac normality: patients with normal coronary arteriograms, healthy volunteers, and uncatheterized patients with a low probability of coronary artery disease. Disease probability was determined by Bayesian analysis of age, sex, symptoms, and the results of cardiac fluoroscopy, exercise electrocardiography, or thallium scintigraphy. A wide range of ventriculographic responses was noted in the 62 catheterized normal patients; 21 (34%) had an abnormal ejection fraction response and 22 (35%) had an abnormal wall motion response. In contrast, the ejection fraction and wall motion responses were normal in the 9 volunteers. In 90 patients (18 catheterized and 72 uncatheterized) who had low disease probability ( < 1%), abnormal responses were rare; the ejection fraction response was abnormal in only 7% and the wall motion response was abnormal in 8%. Thus, these three populations are not equivalent referent standards of normality. Volunteers and patients with low disease probability provide too strict a standard, and their use can overestimate test specificity; catheterized normal patients, on the other hand, provide too lenient a standard, and their use can underestimate test specificity.

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