(Circulation. 1997;95:299-302.)
© 1997 American Heart Association, Inc.
Articles |
Is Noninvasive Testing for Coronary Artery Disease Accurate?
the Cardiovascular Division, Beth Israel Hospital, Harvard Medical School, Harvard-Thorndike Laboratory, Boston, Mass.
Correspondence to Pamela S. Douglas, MD, Cardiovascular Division, Beth Israel Hospital, 330 Brookline Ave, Boston, MA 02215. E-mail pdouglas@bih.harvard.edu
Key Words: Editorials • diagnosis • tests
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Introduction |
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Since the measuring device has been constructed by the observer . . . we have to remember that what we observe is not nature in itself but nature exposed to our method of questioning.
Werner Karl Heisenberg
Physics and Philosophy, 1958
Diagnostic testing forms an important component of cardiovascular medicine, such that optimal practice requires detailed knowledge of how to use and interpret tests. Methods of describing test performance, such as sensitivity and specificity, are widely used with the assumption that they are fairly constant descriptors of the ability of a given test result to detect the presence or absence of disease. Unfortunately, while such concepts are fundamental, accurate assessment of test performance is far more complex, and many factors significantly affect test performance.
In the initial evaluation of a test, investigators often assess its performance by comparing results in populations with very low and very high likelihoods of disease—such as healthy volunteers and afflicted patients. The test in question appears to be an excellent discriminator, although the clinically relevant question of correctly classifying a patient with an intermediate probability of disease has not been addressed. Nevertheless, the published results will indicate very high sensitivity and specificity of the test. However, in subsequent test assessments based on wider use of the test in less clearly segregated populations, they appear to plummet.1 The accuracy of the test has not changed; rather, the population referred for testing has. Thus, apparent test performance can be altered by referral patterns or pretest selection bias. Related to
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