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Problem structure and the use of base-rate information from experience.

This article is concerned with the use of base-rate information that is derived from experience in classifying examples of a category. The basic task involved simulated medical decision making in which participants learned to diagnose hypothetical diseases on the basis of symptom information. Alternative diseases differed in their relative frequency or base rates of occurrence. In five experiments initial learning was followed by a series of transfer tests designed to index the use of base-rate information. On these tests, patterns of symptoms were presented that suggested more than one disease and were therefore ambiguous. The alternative or candidate diseases on such tests could differ in their relative frequency of occurrence during learning. For example, a symptom might be presented that had appeared with both a relatively common and a relatively rare disease. If participants are using base-rate information appropriately (according to Bayes' theorem), then they should be more likely to predict that the common disease is present than that the rare disease is present on such ambiguous tests. Current classification models differ in their predictions concerning the use of base-rate information. For example, most prototype models imply an insensitivity to base-rate information, whereas many exemplar-based classification models predict appropriate use of base-rate information. The results reveal a consistent but complex pattern. Depending on the category structure and the nature of the ambiguous tests, participants use base-rate information appropriately, ignore base-rate information, or use base-rate information inappropriately (predict that the rare disease is more likely to be present). To our knowledge, no current categorization model predicts this pattern of results. To account for these results, a new model is described incorporating the ideas of property or symptom competition and context-sensitive retrieval.

Bayes Theorem↗

Cervical spine fractures in patients 65 years and older: a clinical prediction rule for blunt trauma.

PURPOSE: To determine clinical predictors of cervical spine fracture in the elderly and to develop a clinical prediction rule to guide appropriate imaging in high-risk patients. MATERIALS AND METHODS: Institutional review board approval was received with waiver of informed consent. A retrospective case-control study was performed on blunt trauma patients 65 years and older with cervical spine fractures and on randomly selected control subjects without fracture. Potential predictors of fracture were evaluated through simple and multivariate logistic regression. Simple predictors were grouped into clinically similar composite variables and were analyzed with multivariate logistic regression and recursive partitioning. A clinical prediction rule was generated. The receiver operating characteristic curve was calculated and adjusted through bootstrap validation. Absolute cervical spine fracture probabilities were calculated by using Bayes theorem for all elderly patients and for patients who underwent computed tomography. Results were compared with a previous prediction rule for all adults. RESULTS: Composite predictors of fracture in the elderly included focal neurologic deficit (adjusted odds ratio, 17.7; 95% confidence interval [CI]: 3.8, 83.4), severe head injury (odds ratio, 3.2; 95% CI: 1.5, 7.1), high-energy mechanism (odds ratio 6.7; 95% CI: 3.1, 14.8), and moderate-energy mechanism (odds ratio 3.3; 95% CI: 1.3, 8.3). The prediction rule stratified patients into risk groups with fracture probabilities ranging from 0.4% (95% CI: 0.1%, 1.3%) to 24.2% (95% CI: 5.7%, 100%). CONCLUSION: Clinical factors can be used to stratify patients 65 years and older into risk groups with a wide range of probabilities of cervical spine fracture. Knowledge of cervical fracture risk can help guide appropriate imaging in high-risk patients.

Aged↗

Can the presumed risk of autosomal trisomy be decreased in fetuses of older women following a normal sonogram?

Previous studies showed that a sonographic scoring system can be used to identify women under age 35 who are at an increased risk for a fetal autosomal trisomy. We propose to use the same scoring system to select women over age 35 who are at a decreased risk of a fetal autosomal trisomy because the ultrasonogram is normal. We reviewed the sonographic scores of 97 trisomic and 694 normal control fetuses from two previously published consecutive series designed to identify women at increased risk for an affected fetus. Using the same scoring index in this study, we calculated the sensitivity and specificity of a score = 0 zero for identifying fetuses with autosomal trisomy. We then applied Bayes' theorem to determine the probability of an autosomal trisomy at various maternal ages, given a sonographic score of 0. Of the 97 fetuses with an autosomal trisomy, 83 had a score of > or = 1, for a sensitivity of 86% (95% CI 77-92%). Of the 694 control fetuses with normal karyotype, 606 had a score of 0, for a specificity of 87% (95% CI 83-89%). A 42 year old woman's probability of an autosomal trisomy if the sonographic score is 0 becomes equivalent to the age-specific probability for a 35 year old woman. Using the lower limit of the CIs for sensitivity and specificity, we calculated that the probability of having a fetus with an autosomal trisomy falls from 18.8 in 1000 to 5.3 in 1000 for a 40 year old woman with a sonographic score of 0.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

Adenosine deaminase and interferon gamma measurements for the diagnosis of tuberculous pleurisy: a meta-analysis.

OBJECTIVE: As Mycobacterium tuberculosis isolation rates in tuberculous effusions are relatively low, several biochemical and immunological markers have been proposed to diagnose tuberculous pleurisy including adenosine deaminase (ADA) and interferon-gamma (IFN-gamma). Here we summarise the literature on ADA and IFN-gamma as predictors of tuberculous pleurisy. METHODS: After a systematic review of English language studies, we used summary receiver operating characteristic curve (SROC) analysis to determine the cumulative diagnostic accuracy of both markers and Bayes' theorem to calculate post-test probability of disease in settings with different prevalences of tuberculous pleurisy, assessed and reported the quality of primary studies. RESULTS: From 1978 to November 2000, studies containing sufficient data for the determination of both sensitivity and specificity were 31 on ADA, including 4738 patients, and 13 on IFN-gamma, including 1189 patients. SROC curve yielded a maximum joint sensitivity and specificity of 93% for ADA and 96% for IFN-gamma. In the setting of tuberculous effusion prevalence of 5%, 25% and 85%, post-test probability of a negative ADA test were 0.4%, 2.4% and 24%, and 0.22%, 1.2% and 17% for a negative IFN-gamma test. CONCLUSION: With the caveat that limitations in the design of the studies summarised here may distort estimates of test performance, ADA and IFN-gamma appear to be reasonably accurate at detecting TB pleurisy.

Adenosine Deaminase↗

What is the probability of a patient presenting a pleural effusion due to tuberculosis?

INTRODUCTION: In Rio de Janeiro, in almost half of the cases of pleural tuberculosis (PT) treatment begins without substantiation of diagnosis. We examined variables associated with this disease. METHOD: We studied 215 consecutive patients; 104 had tuberculosis (TB) and 111 did not (NTB): 41 neoplasms, 29 transudates, 28 para-pneumonic and 13 other etiologies. Clinical and laboratory variables were assessed in a combined manner using likelihood ratios (LR) and Bayes' theorem to determine the probability of PT. RESULTS: Among the variables examined, adenosine deaminase (ADA) levels, lymphocyte cell percentage, protein and age were the best indicators for the diagnosis of PT. Association of ADA with any of the other variables led to a LR+ higher than 10 and a LR- lower than 0.1, indicating the presence or absence of PT, with an individual probability of more than 90% or of less than 10% considering that there was a 50% initial probability associated with the presence of PT. CONCLUSIONS: Since ADA is highly sensitive, we can practically exclude TB as the cause of effusion when there are low ADA values. However, to confirm the possibility of TB we recommend that other variables, such as prevalence of lymphocytes (higher than 90%), and high protein levels (more than 4 g/dL); low age (less than 45 years) also should be considered.

Adenosine Deaminase↗

Post-test probability of asthma following methacholine challenge.

Using recently published data, a nomogram was constructed to estimate the likelihood of asthma following methacholine challenge. Based on Bayes' theorem, the nomogram makes use of the sensitivity and specificity of methacholine challenge to calculate the post-test probability of asthma once the physician makes a determination of the pretest probability, that is, the likelihood of asthma before the test results are considered. A family of curves is presented to cover several levels of cumulative breath units at which the test could become positive, and a single curve is presented for a negative test after 224 cumulative breath units. Separate curves are presented for smokers and nonsmokers. The estimate of pretest probability is most crucial in negative tests where likelihood of asthma is considered high, and in positive tests in patients in whom asthma is considered unlikely. Although these curves will not apply precisely to a different data base, the concept of the relationship between pretest and post-test probability helps in the interpretation of the test results and stresses the importance of using all available information in making a diagnosis.

Asthma↗

Role of duodenography in the diagnosis of blunt duodenal injuries.

BACKGROUND: The differentiation of duodenal perforation from duodenal hematoma is not always possible with computed tomography (CT). Our diagnostic guideline has included duodenography to investigate CT findings of periduodenal fluid or wall thickening. However, the utility of duodenography as a diagnostic study in blunt abdominal trauma is not defined. We evaluated duodenography as a diagnostic test in patients with suspected blunt duodenal injuries (BDIs). METHODS: During a 10-year period, 96 patients out of 25,608 trauma admissions had CT findings of possible BDI and underwent duodenography. Demographic and clinical data, diagnostic methods, and management were derived from prospectively collected data. CT and duodenography studies were reviewed and correlated with surgical findings and outcome. All CT scans were obtained with intravenous contrast; oral contrast was used in 32 patients. Duodenography was analyzed using the 2 x 2 method and Bayes theorem. RESULTS: Indications for duodenography included periduodenal fluid without extravasation (76%), abnormal duodenal wall thickening (16%), and retroperitoneal extraluminal gas (5%). Eighty-six duodenography studies were reported as normal, six were consistent with hematoma, one was indeterminate, and only three revealed extravasation. Two of these three patients with duodenal perforation had retroperitoneal extraluminal air. Only one patient underwent exploration on the basis of duodenography. No blunt duodenal perforation was diagnosed by CT. Overall, duodenography had sensitivity of 54% and specificity of 98%. For BDIs requiring repair, duodenography sensitivity was only 25%; the false-negative rate was also 25%. Retroperitoneal extraluminal air was a useful sign of duodenal perforation, occurring in two of three patients with BDI and only in one without BDI (p < 0.001). CONCLUSION: Duodenography has a low sensitivity in patients with suspected BDI by CT findings and is of minimal utility in diagnostic evaluation. Retroperitoneal extraluminal air seen on CT is an important sign of BDI requiring surgical repair.

Adolescent↗

Lifetime prevalence of uveal melanoma in white patients with oculo(dermal) melanocytosis.

OBJECTIVE: In the white population, an association between oculo(dermal) melanocytosis (ODM) and uveal melanoma is well recognized. However, the lifetime prevalence of uveal melanoma in the ODM population is not known. This study was designed to determine the lifetime prevalence of uveal melanoma among patients with ocular melanocytosis. DESIGN: Fifty-six white patients manifesting ODM with uveal melanoma formed the basis of the study. MAIN OUTCOME MEASURES: Published prevalence rates of ODM and uveal melanoma were used for calculations using Bayes' theorem. RESULTS: The lifetime prevalence of uveal melanoma in white patients with ODM is estimated to be 2.6 x 10(-3). The median age at diagnosis of uveal melanoma in the ODM population was similar to a randomly selected population (60.5 years and 62.5 years, respectively). In the vast majority of patients (90%) with ODM-associated uveal melanoma, the uveal melanoma was diagnosed between the ages of 31 years and 80 years. CONCLUSIONS: One of about 400 patients with ODM followed for life is estimated to develop uveal melanoma. Excessive melanocytes in the uveal tract in ODM may provide the biologic basis for susceptibility to the development of uveal melanoma. Patients with ODM should be monitored ophthalmoscopically, especially during the susceptible period, for the development of uveal melanoma. The authors suggest that a national registry of ODM patients be created and prospective data collected to better assess the risk of developing uveal melanoma.

Adolescent↗

Probability of axillary lymph node metastasis when sentinel lymph node biopsy is negative in women with clinically node negative breast cancer: a Bayesian approach.

BACKGROUND: Although sentinel lymph node biopsy(SLNB)is highly accurate in predicting axillary nodal status in patients with breast cancer, it has been shown that the procedure is associated with a few false negative results. The risk of leaving metastatic nodes behind in the axillary basin when SLNB is negative should be estimated for an individual patient if SLNB is performed to avoid conventional axillary lymph node dissection(ALND). METHODS: A retrospective analysis of 512 women with T1-3N0M0 breast cancer was conducted to derive a prevalence of nodal metastasis by T category as a pre-test(i.e., before SLNB)probability and to examine potential confounders on the relationship between T category and axillary nodal involvement. Probability of nodal metastasis when SLNB was negative was estimated by means of Bayes' theorem which incorporated the pre-test probability and sensitivity and specificity of SLNB. RESULTS: Axillary nodal metastasis was observed in 6.1% of T1a-b, 25.1% of T1c, 28.7% of T2, 35.0% of T3 tumors. Point estimates for the probability of nodal involvement when SLNB was negative ranged from 0.3-1.3% for T1a-b, 1.6-6.3% for T1c, 2.0-7.5% for T2, and 2.6-9.7% for T3 tumors with representative sensitivities of 80%, 85%, 90% and 95%, respectively. The risk may be higher when the tumor involves the upper outer quadrant of the breast, while it may be lower for an underweight woman. CONCLUSIONS: The probability of axillary lymph node metastasis when SLNB is negative can be estimated using a Bayesian approach. Presenting the probability to the patient may guide the decision of surgery without conventional ALND.

Adult↗

An isolated echogenic heart focus is not an indication for amniocentesis in 12,672 unselected patients.

OBJECTIVE: To evaluate the risk of Down syndrome in fetuses with a heart echogenic focus using the Bayes theorem and likelihood ratios in an unselected population. METHODS: We prospectively evaluated 12,672 second-trimester sonographic features and extracted and examined a population with an echogenic focus for chromosomal anomalies. RESULTS: There were 479 cases of echogenic focus; 90.4% were isolated, whereas 9.6% had associated findings. Eleven patients had fetuses with trisomy 21 (9 per 10,000). Eight of those did not have an echogenic focus, whereas 3 had a heart echogenic focus. Only 1 fetus with trisomy 21 had an isolated echogenic focus. The positive likelihood ratio for total cases of a heart echogenic focus and trisomy 21 was 7.25, whereas for an isolated echogenic focus, the positive likelihood ratio was 2.66. CONCLUSIONS: The results of the statistical analysis showed that the risk of aneuploidy is increased in fetuses with an echogenic intracardiac focus; however, the finding should prompt a detailed structural survey and correlation with a priori risk. Amniocentesis need not be offered to patients who are otherwise at low risk and have an isolated echogenic intracardiac focus.

Adolescent↗

An algorithm for differential diagnosis in jaundice and its applications.

During the recent years a broad spectrum of diagnostic methods have appeared for the differentiation of obstructive and nonobstructive jaundice: ultrasound examination, CT-scan, direct cholangiography, etc. These investigations are costly and not without risks. It is therefore essential to devise an optimal diagnostic strategy for each patient. Extensive clinical and clinical chemical information was collected from 1,002 jaundiced patients. By application of Bayes' theorem and logistic discriminant analysis a diagnostic algorithm was developed based upon 21 variables of the 107 variables collected. This algorithm permitted a probabilistic classification of jaundiced patients into four diagnostic categories: acute non-obstructive, chronic non-obstructive, benign obstructive and malignant obstructive jaundice. Adopting a probability limit of 0.80, 683 patients (69 p. 100) were correctly classified, 34 patients (3.5 p. 100) were wrongly so, and 268 patients (27 p. 100) could not be classified with a probability above 0.80 (doubtful cases). The algorithm was also tested in a further series of 110 jaundiced patients and found to perform equally well: 88 patients classified, 22 patients remaining doubtful. Patients with doubtful diagnoses should be referred to a non-invasive test such as ultrasound examination, whereas patients with definite diagnoses can be referred to invasive tests (liver biopsy, direct cholangiography) as appropriate. The diagnostic algorithm seems to be a reliable tool for the primary differential diagnosis of the jaundiced patient and can be used in the planning of further diagnostic tests for the individual patient.

Algorithms↗

A probabilistic expert system that provides automated mammographic-histologic correlation: initial experience.

OBJECTIVE: We sought to determine whether a probabilistic expert system can provide accurate automated imaging-histologic correlations to aid radiologists in assessing the concordance of mammographic findings with the results of imaging-guided breast biopsies. MATERIALS AND METHODS: We created a Bayesian network in which Breast Imaging Reporting and Data System (BI-RADS) descriptors are used to convey the level of suspicion of mammographic abnormalities. Our system is a computer model that links BI-RADS descriptors with diseases of the breast using probabilities derived from the literature. Mammographic findings are used to update pretest probabilities (prevalence of disease) into posttest probabilities applying Bayes' theorem. We evaluated the histologic results of 92 consecutive imaging-guided breast biopsies for concordance with the mammographic findings during radiology-pathology review sessions. First, radiologists with no knowledge of the biopsy results chose BI-RADS descriptors for the mammographic findings. After the histologic diagnosis was revealed, the radiologists assessed concordance between the pathologic results and the mammographic findings. We then input the information gathered from these sessions into the Bayesian network to produce an automated mammographic-histologic correlation. RESULTS: We had a sampling error rate of 1.1% (1/92 biopsies). Our expert system was able to integrate pathologic diagnoses and mammographic findings to obtain probabilities of sampling error, thereby enabling us to identify the incorrect pathologic diagnosis with 100% sensitivity while maintaining a specificity of 91%. CONCLUSION: Our probabilistic expert system has the potential to help radiologists in identifying breast biopsy results that are discordant with mammographic findings and discovering cases in which biopsy sampling errors may have occurred.

Adult↗

[Predictive value of exercise-induced ST depression in the diagnosis of restenosis after coronary angioplasty].

Exercise tests systematically performed during coronary arteriography in patients who had undergone coronary angioplasty show a very large number of ST depressions in the absence of significant coronary lesion. This could be ascribed either to electrocardiographic traces of chronic ischaemia or to a reduced predictive value of exercise tests due to a combination of low prevalence of coronary disease and poor specificity and/or sensitivity. In order to confirm or infirm these hypotheses, the values observed in a study group of 122 patients who had undergone angioplasty for single lesion of the anterior interventricular artery were compared with the values calculated by Bayes' theorem from a 30 p. 100 theoretical restenosis rate and a sensitivity and specificity calculated from a group of control patients who did not have coronary angioplasty but showed the same coronary arteriographic characteristics as the study group. In the study group as in the control group, sensitivity (60 versus 67 p. 100) and specificity (56 versus 54 p. 100) were low. Positive predictive values were also very low (33 versus 38 p. 100), whereas negative values were acceptable (78 p. 100 in both groups). Differences between groups were not significant. The predictive value of ST depression in the diagnosis of post-angioplasty restenosis is too low to be used alone. This low predictive value can be ascribed to the low prevalence of restenosis and to the extremely low specificity observed in the presence of non significant lesions. However, the finding of a negative exercise test in asymptomatic patients enables coronary arteriography to be avoided with a low risk of error (7.7 p. 100).

Angioplasty, Balloon↗

Probabilistic reasoning and clinical decision-making: do doctors overestimate diagnostic probabilities?

BACKGROUND: The "threshold approach" is based on a physician's assessment of the likelihood of a disease expressed as a probability. The use of Bayes' theorem to calculate disease probability in patients with and without a particular characteristic, may be hampered by the presence of subadditivity (i.e. the sum of probabilities concerning a single case scenario exceeding 100%). AIM: To assess the presence of subadditivity in physicians' estimations of probabilities and the degree of concordance among doctors in their probability assessments. DESIGN: Prospective questionnaire. METHODS: Residents and trained physicians in Family Medicine, Internal Medicine and Cardiology (n = 84) were asked to estimate the probability of each component of the differential diagnosis in a case scenario describing a patient with chest pain. RESULTS: Subadditivity was exhibited in 65% of the participants. The total sum of probabilities given by each participant ranged from 44% to 290% (mean 137%). There was wide variability in the assignment of probabilities for each diagnostic possibility (SD 16-21%). DISCUSSION: The finding of substantial subadditivity, coupled with the marked discordance in probability estimates, questions the applicability of the threshold approach. Physicians need guidance, explicit tools and formal training in probability estimation to optimize the use of this approach in clinical practice.

Bayes Theorem↗

Relationship between leukocyte count and patient risk for excessive blood loss after cardiac surgery.

OBJECTIVE: To evaluate the relationship between leukocyte counts and risk for excessive blood loss after cardiac surgery when including numerous demographic, operative, and laboratory factors in the comparison. DESIGN: A prospective, clinical evaluation. SETTING: A point-of-care laboratory and the cardiac surgical unit of a university-affiliated tertiary center. PATIENTS: Patient-related and hematologic variables were measured, using blood specimens obtained from 89 hospitalized patients who underwent cardiac surgery involving cardiopulmonary bypass. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic, operative, and transfusion-related data were recorded for each patient. Routinely obtained measurements of laboratory-based prothrombin time, partial thromboplastin time, complete blood count, and bleeding time were recorded. Hemoglobin concentration, platelet count, and red and white blood cell counts were measured with an on-site instrument before initiation (pre-cardiopulmonary bypass) and before discontinuation (end-cardiopulmonary bypass) of cardiopulmonary bypass. Hematocrit was calculated using recorded variables, and white blood cell percent change values were calculated using white blood cell counts from both periods, using the following formula: [(end-cardiopulmonary bypass - pre-cardiopulmonary bypass)/pre-cardiopulmonary bypass] x 100. When we excluded four patients who had a surgical source of post-cardiopulmonary bypass bleeding, significant (p < .0001) relationships were observed between white blood cell count (r2 = .46) and white blood cell percent change values (r2 = .71) and cumulative mediastinal chest tube drainage in the first 4 postoperative hours in 85 patients. Bayes theorem was used to evaluate the predictive ability of hematologic measurements in identifying patients with excessive bleeding (n = 24), defined as >1000 mL of cumulative chest tube drainage in the first 24 postoperative hours, when compared with patients without excessive bleeding (n = 61). Demographic and operative variables were similar between these patients except that patients with excessive bleeding required more red blood cell, platelet, and plasma transfusions during the postoperative interval. Significantly (p < .0001) greater white blood cell percent change values were obtained in the excessive bleeding cohort (119 +/- 93 percent change) when compared with patients without excessive bleeding (28 +/- 36 percent change). CONCLUSIONS: On-site measurements of white blood cell count, as an index of the inflammatory response to extracorporeal circulation, may be useful in identifying patients at increased risk for excessive bleeding. Further studies are needed to examine whether white blood cell counts during multiple cardiopulmonary bypass periods may identify patients with an exaggerated inflammatory response to extracorporeal circulation. By using this information, physicians may be able to intervene with anti-inflammatory medications and blood preservation techniques.

Adult↗

[Bayesian methodology: an alternative to regular medical practice].

The Bayes theorem provides a formula to calculate the probability of an event to occur conditioned by the occurrence of an anterior one (conditioned probability). In medicine it has been applied to calculate the probability of suffering a disease when having a positive result in a given test. This formula emphasizes the importance of prevalence of a disease (or a priori probability of the positive predictive value of a diagnostic test). The novelty of applying the bayesian methodology in clinical practice results from taking into consideration previous external information (or "a priori probability"), and to calculate how it is modified by the evidence (or "verisimilitude") provided by certain empirical tests, to obtain a new probability conditioned by the empirical evidence (or "a posteriori probability"). It also allows to perform sequential analysis (repeated observation of a given event a number of times not fixed in advance) and to incorporate the subjective probabilities to the reasoning. Some authors have proposed the use of bayesian methodology in research studies, such as clinical trials. Nevertheless, this methodology does not adapt well to this kind of reasoning which is hypothetical-deductive.

Bayes Theorem↗

A hybrid Bayesian-neural network approach for probabilistic modeling of bacterial growth/no-growth interface.

A hybrid probabilistic modeling approach that integrates artificial neural networks (ANNs) with statistical Bayesian conditional probability estimation is proposed. The suggested approach benefits from the power of ANNs as highly flexible nonlinear mapping paradigms, and the Bayes' theorem for computing probabilities of bacterial growth with the aid of Parzen's probability distribution function estimators derived for growth and no-growth (G/NG) states. The proposed modeling approach produces models that can predict the probability of growth of targeted microorganism as affected by a set of parameters pertaining to extrinsic factors and operating conditions. The models also can be used to define the probabilistic boundary (interface) between growth and no-growth, and as such can define and predict the values of critical parameters required to keep a desired pre-specified bacterial growth risk in check. A modular system incorporating the various computational modules was constructed to illustrate the application of the hybrid approach to the probabilistic modeling of growth of pathogenic Escherichia coli strain as affected by temperature and water activity. The proposed approach was compared to other techniques including the traditional linear and nonlinear logistic regression. Results indicated that the hybrid approach outperforms the other approaches in its accuracy as well as flexibility to extract the implicit interrelationships between the various parameters. Advantages and limitations of the approach were also discussed and compared to those of other techniques.

Bayes Theorem↗

Diagnostic value of computerized exercise testing in men without previous myocardial infarction. A multivariate, compartmental and probabilistic approach.

The value of exercise testing for the diagnosis of coronary artery disease is disputed but very few studies have taken advantage of all recent improvements, namely computer averaging of the ECG signals, multivariate analysis of the data, a compartmental diagnostic approach and probabilistic interpretation of the results. These methods were tested in a group of 387 men who had a computer-assisted multistage maximal exercise test; none had a history of myocardial infarction. In 284 symptomatic patients, the diagnosis was made by arteriography; 103 ostensibly healthy men were also included. The computer-averaged ECG signals (X, Y, Z) recorded at maximal exercise, maximal heart rate, blood pressure and workload, and the onset of angina pectoris during exercise were submitted to a multivariate stepwise discriminant analysis. The pretest likelihood for CAD was calculated from age and history; the post-test likelihood was calculated from Bayes' theorem and the average information content of several diagnostic methods was assessed in categorical and compartmental models. By multivariate analysis, 5 variables collected at maximal exercise were selected, namely the heart-rate, the ST60 segment level, the onset of angina during the test, the workload and the slope of the ST segment in lead X. The average information content of the analysis using 5 variables was 44% in a categorical model versus 55% in a compartmental model (P less than 0.001). For comparison, the information content of the analysis using the ST60 segment level alone was only 16% in the categorical model and 27% in the compartmental model. The clinical value of these diagnostic methods (categorical versus compartmental, univariate versus multivariate) was assessed by a probabilistic classification of the patients. The classification provided by the analysis of the ST60 segment changes was barely better than that one provided by the simple history. The probabilistic use of a multivariate and compartmental analysis of the data led to a significantly better and more accurate classification of the patients (83% of correct classification).

Adult↗