Okin P M, Kligfield P
Department of Medicine, New York Hospital-Cornell Medical Center, New York 10021, USA.
Circulation. 1995 Sep 1;92(5):1209-16. doi: 10.1161/01.cir.92.5.1209.
Significant gender differences have been found in performance of the exercise ECG for the identification of coronary artery disease. However, identical exercise ECG ST segment criteria have been used in men and women, which might contribute to the lower accuracy of these methods in women than in men.
To assess the effect of gender-specific test partitions on relative performance of standard and heart rate-adjusted ST segment depression criteria in men and women, the exercise ECGs of 143 women and 477 men were examined. Non-gender-specific test partitions, selected to have matched specificities of 96% for each test method, were determined in all 283 normal subjects, and gender-specific test partitions with identical specificity were determined separately in the 52 normal women and 231 normal men; sensitivity of these criteria was then examined in the 91 women and 246 men with coronary disease. Standard ST segment depression criteria (0.1 mV of additional horizontal or downsloping ST segment depression at end exercise) with identical 96% specificity in the entire group of normal subjects and separately in women and men had a significantly lower sensitivity of 51% in women compared with 67% in men (P < .01). Among women, performance of the ST segment/heart rate (ST/HR) slope was more improved than that of the ST/HR index by the use of gender-specific criteria. Compared with the performance of non-gender-specific criteria, application of gender-specific ST/HR slope partitions with matched specificity of 96% resulted in a significant increase in sensitivity in women from 84% to 91% (P < .01), with no significant change in sensitivity in men (89% to 88%) and with no residual difference in sensitivity between men and women. Although the use of gender-specific ST/HR slope criteria significantly improved sensitivity in both men and women with respect to standard criteria (each P < .0001), the relative increase in sensitivity provided by heart rate adjustment was significantly greater in women than in men (40% versus 21%, P < .001). Similar gender differences in improvement in performance using gender-specific criteria for the ST/HR slope were observed when analysis of test performance was restricted to the detection of three-vessel coronary disease (50% versus 9%, P = .002).
At high specificity, gender-specific test partitions improve sensitivity of the ST/HR slope for the identification of coronary disease in women, with no decrease in sensitivity in men. In contrast, gender-specific partitions do not change performance of standard test criteria, which is lower in women than in men. Accordingly, the relative benefit of heart rate adjustment by the ST/HR slope method is greater in women than in men. These findings support use of the ST/HR slope with use of gender-specific partitions for the identification and quantification of coronary artery disease in both men and women.
在用于识别冠状动脉疾病的运动心电图检查中发现了显著的性别差异。然而，男性和女性使用的运动心电图ST段标准相同，这可能导致这些方法在女性中的准确性低于男性。
为了评估特定性别的测试划分对标准和心率校正的ST段压低标准在男性和女性中相对性能的影响，对143名女性和477名男性的运动心电图进行了检查。在所有283名正常受试者中确定了非特定性别的测试划分，以使每种测试方法的特异性匹配为96%，并在52名正常女性和231名正常男性中分别确定了具有相同特异性的特定性别的测试划分；然后在91名患有冠状动脉疾病的女性和246名男性中检查了这些标准的敏感性。在整个正常受试者组以及分别在女性和男性中具有相同96%特异性的标准ST段压低标准（运动结束时额外的水平或下斜ST段压低0.1 mV），在女性中的敏感性显著低于男性，分别为51%和67%（P <.01）。在女性中，使用特定性别的标准时，ST段/心率（ST/HR）斜率的性能比ST/HR指数的性能改善更大。与非特定性别的标准性能相比，应用特异性匹配为96%的特定性别的ST/HR斜率划分导致女性的敏感性从84%显著增加到91%（P <.01），男性的敏感性没有显著变化（89%至88%），且男性和女性之间的敏感性没有残留差异。尽管使用特定性别的ST/HR斜率标准相对于标准标准在男性和女性中均显著提高了敏感性（每个P < .0001），但心率校正提供的敏感性相对增加在女性中显著大于男性（40%对21%，P <.001）。当将测试性能分析限制在检测三支血管冠状动脉疾病时，在使用特定性别的ST/HR斜率标准时，在性能改善方面也观察到了类似的性别差异（50%对9%，P =.002）。
在高特异性时，特定性别的测试划分可提高ST/HR斜率在识别女性冠状动脉疾病中的敏感性，而男性的敏感性没有降低。相比之下，特定性别的划分不会改变标准测试标准的性能，而该性能在女性中低于男性。因此，ST/HR斜率方法进行心率校正的相对益处在女性中大于男性。这些发现支持使用ST/HR斜率并结合特定性别的划分来识别和量化男性和女性的冠状动脉疾病。
