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Maros Ferencik - One of the best experts on this subject based on the ideXlab platform.
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early noninvasive Cardiac Testing after emergency department evaluation for suspected acute coronary syndrome
JAMA Internal Medicine, 2020Co-Authors: Aniket A Kawatkar, Adam L Sharp, Aileen Baecker, Shaw Natsui, Rita F Redberg, Mingsum Lee, Maros Ferencik, Ernest Shen, Chengyi Zheng, Visanee V MusigdilokAbstract:Importance Professional guidelines recommend noninvasive Cardiac Testing (NIT) within 72 hours of an emergency department (ED) evaluation for suspected acute coronary syndrome. However, there is inexact evidence that this strategy reduces the risk of future death or acute myocardial infarction (MI). Objective To evaluate the effectiveness of early NIT in reducing the risk of death or acute MI within 30 days. Design, Setting, and Participants This retrospective, multicenter cohort study within the Kaiser Permanente Southern California integrated health care delivery system compared the effectiveness of early noninvasive Cardiac Testing vs no Testing in patients with chest pain and in whom acute MI was ruled out who presented to an ED from January 2015 to December 2017. Patients were followed up for up to 30 days after emergency department discharge. Exposures Noninvasive Cardiac Testing performed within 3 days of an ED evaluation for suspected acute coronary syndrome. Main Outcomes and Measures The primary outcome was composite risk of death or acute MI, within 30 days of an ED discharge. Results A total of 79 040 patients were evaluated in this study, of whom 57.7% were female. The mean (SD) age of the cohort was 57 (16) years, and 16 164 patients (21%) had completed early NIT. The absolute risk of death or MI within 30 days was low (<1%). Early NIT had the minor benefit of reducing the absolute composite risk of death or MI (0.4% [95% CI, -0.6% to -0.3%]), and, separately, of death (0.2% [95% CI, -0.2% to -0.1%]), MI (-0.3% [95% CI, -0.5% to -0.1%]), and major adverse Cardiac event (-0.5% [95% CI, -0.7% to -0.3%]). The number needed to treat was 250 to avoid 1 death or MI, 500 to avoid 1 death, 333 to avoid 1 MI, and 200 to avoid 1 major adverse cardiovascular event within 30 days. Subgroup analysis revealed a number needed to treat of 14 to avoid 1 death or MI in the subset of patients with elevated troponin. Conclusions and Relevance Early NIT was associated with a small decrease in the risk of death or MI in patients admitted to the ED with suspected acute coronary syndrome, but this clinical strategy may not be optimal for most patients given the large number needed to treat.
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high sensitivity Cardiac troponin i as a gatekeeper for coronary computed tomography angiography and stress Testing in patients with acute chest pain
Clinical Chemistry, 2017Co-Authors: Maros Ferencik, Thomas Mayrhofer, Pamela K Woodard, Quynh A Truong, Frank W Peacock, Fabian Bamberg, Benjamin C Sun, Jerome L Fleg, John T NagurneyAbstract:BACKGROUND: Most patients presenting to the emergency department (ED) with suspected acute coronary syndrome (ACS) undergo noninvasive Cardiac Testing with a low diagnostic yield. We determined whether a combination of high-sensitivity Cardiac troponin I (hs-cTnI) and cardiovascular risk factors might improve selection of patients for Cardiac Testing. METHODS: We included patients from the Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography (ROMICAT) I and II trials who presented to the ED with acute chest pain and were referred for Cardiac Testing. Based on serial hs-cTnI measurements and cardiovascular risk factors, we derived and validated the criterion for no need of Cardiac Testing. We predicted the effect of this criterion on the effectiveness of patient management. RESULTS: A combination of baseline hs-cTnI ( CONCLUSIONS: We derived and validated a criterion for combined hs-cTnI and cardiovascular risk factors that identified acute chest pain patients with no need for Cardiac Testing and could improve effectiveness of patient management. ClinicalTrials.gov Identifiers: NCT00990262 and NCT01084239
Angela C Webster - One of the best experts on this subject based on the ideXlab platform.
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Cardiac Testing for coronary artery disease in potential kidney transplant recipients
Nephrology, 2012Co-Authors: Louis W. Wang, Magid Fahim, Andrew Hayen, Ruth L. Mitchell, Laura A. Baines, Stephen R. Lord, Jonathan C. Craig, Angela C WebsterAbstract:Dobutamine stress echocardiography [pooled sensitivity 0.79, 95% CI 0.67 to 0.88, pooled specificity 0.89, 95% CI 0.81 to 0.94] and myocardial perfusion scintigraphy [pooled sensitivity 0.74, 95% CI 0.54 to 0.87, pooled specificity 0.70, 95% CI 0.51 to 0.84] had moderate sensitivity and specificity in detecting coronary artery disease. There was evidence that Dobutamine stress echocardiography had improved accuracy over myocardial perfusion scintigraphy (P = 0.02) when all studies were included in the analysis, but this was not significant when we excluded studies of poorer methodological quality, or which defined significant coronary disease using a higher threshold of 70% stenosis (P = 0.09).
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The Cochrane Library - Cardiac Testing for coronary artery disease in potential kidney transplant recipients
Nephrology (Carlton Vic.), 2012Co-Authors: Louis W. Wang, Magid Fahim, Andrew Hayen, Ruth L. Mitchell, Laura A. Baines, Stephen R. Lord, Jonathan C. Craig, Angela C WebsterAbstract:Dobutamine stress echocardiography [pooled sensitivity 0.79, 95% CI 0.67 to 0.88, pooled specificity 0.89, 95% CI 0.81 to 0.94] and myocardial perfusion scintigraphy [pooled sensitivity 0.74, 95% CI 0.54 to 0.87, pooled specificity 0.70, 95% CI 0.51 to 0.84] had moderate sensitivity and specificity in detecting coronary artery disease. There was evidence that Dobutamine stress echocardiography had improved accuracy over myocardial perfusion scintigraphy (P = 0.02) when all studies were included in the analysis, but this was not significant when we excluded studies of poorer methodological quality, or which defined significant coronary disease using a higher threshold of 70% stenosis (P = 0.09).
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Cardiac Testing for coronary artery disease in potential kidney transplant recipients.
The Cochrane database of systematic reviews, 2011Co-Authors: Louis W. Wang, Magid Fahim, Andrew Hayen, Ruth L. Mitchell, Laura A. Baines, Stephen R. Lord, Jonathan C. Craig, Angela C WebsterAbstract:Background Patients with chronic kidney disease (CKD) are at increased risk of coronary artery disease (CAD) and adverse Cardiac events. Screening for CAD is therefore an important part of preoperative evaluation for kidney transplant candidates. There is significant interest in the role of non-invasive Cardiac investigations and their ability to identify patients at high risk of CAD. Objectives We investigated the accuracy of non-invasive Cardiac screening tests compared with coronary angiography to detect CAD in patients who are potential kidney transplant recipients. Search methods MEDLINE and EMBASE searches (inception to November 2010) were performed to identify studies that assessed the diagnostic accuracy of non-invasive screening tests, using coronary angiography as the reference standard. We also conducted citation tracking via Web of Science and handsearched reference lists of identified primary studies and review articles. Selection criteria We included in this review all diagnostic cross sectional, cohort and randomised studies of test accuracy that compared the results of any Cardiac test with coronary angiography (the reference standard) relating to patients considered as potential candidates for kidney transplantation or kidney-pancreas transplantation at the time diagnostic tests were performed. Data collection and analysis We used a hierarchical modelling strategy to produce summary receiver operating characteristic (SROC) curves, and pooled estimates of sensitivity and specificity. Sensitivity analyses to determine test accuracy were performed if only studies that had full verification or applied a threshold of ≥ 70% stenosis on coronary angiography for the diagnosis of significant CAD were included. Main results The following screening investigations included in the meta-analysis were: dobutamine stress echocardiography (DSE) (13 studies), myocardial perfusion scintigraphy (MPS) (nine studies), echocardiography (three studies), exercise stress electrocardiography (two studies), resting electrocardiography (three studies), and one study each of electron beam computed tomography (EBCT), exercise ventriculography, carotid intimal media thickness (CIMT) and digital subtraction fluorography (DSF). Sufficient studies were present to allow hierarchical summary receiver operating characteristic (HSROC) analysis for DSE and MPS. When including all available studies, both DSE and MPS had moderate sensitivity and specificity in detecting coronary artery stenosis in patients who are kidney transplant candidates [DSE (13 studies) - pooled sensitivity 0.79 (95% CI 0.67 to 0.88), pooled specificity 0.89 (95% CI 0.81 to 0.94); MPS (nine studies) - pooled sensitivity 0.74 (95% CI 0.54 to 0.87), pooled specificity 0.70 (95% CI 0.51 to 0.84)]. When limiting to studies which defined coronary artery stenosis using a reference threshold of ≥ 70% stenosis on coronary angiography, there was little change in these pooled estimates of accuracy [DSE (9 studies) - pooled sensitivity 0.76 (95% CI 0.60 to 0.87), specificity 0.88 (95% CI 0.78 to 0.94); MPS (7 studies) - pooled sensitivity 0.67 (95% CI 0.48 to 0.82), pooled specificity 0.77 (95% CI 0.61 to 0.88)]. There was evidence that DSE had improved accuracy over MPS (P = 0.02) when all studies were included in the analysis, but this was not significant when we excluded studies which did not avoid partial verification or use a reference standard threshold of ≥70% stenosis (P = 0.09). Authors' conclusions DSE may perform better than MPS but additional studies directly comparing these Cardiac screening tests are needed. Absence of significant CAD may not necessarily correlate with Cardiac-event free survival following transplantation. Further research should focus on assessing the ability of functional tests to predict postoperative outcome.
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Cardiac Testing for coronary artery disease in potential kidney transplant recipients a systematic review of test accuracy studies
American Journal of Kidney Diseases, 2011Co-Authors: Louis W. Wang, Magid Fahim, Andrew Hayen, Ruth L. Mitchell, Laura A. Baines, Jonathan C. Craig, Angela C Webster, S W LordAbstract:Background Cardiovascular disease is the leading cause of death after kidney transplant. Screening for coronary artery disease is integral to pretransplant evaluation, although the relative performance of different tests is uncertain. Study Design Systematic review of diagnostic test accuracy studies using hierarchical summary receiver operating characteristic analysis. Setting & Population Kidney transplant candidates undergoing pretransplant assessment. Selection Criteria of Studies Studies evaluating the accuracy of screening tests for detecting coronary artery disease. Index Tests Any non- or minimally invasive test used to diagnose coronary artery disease. Reference Test Coronary angiography. Results 11 studies (690 participants) evaluated dobutamine stress echocardiography; 7 (317 participants), myocardial perfusion scintigraphy; 2 (129 participants), exercise stress electrocardiography; and 2 (121 participants), other tests. Dobutamine stress echocardiography had pooled sensitivity of 0.80 (95% CI, 0.64-0.90) and specificity of 0.89 (95% CI, 0.79-0.94). Myocardial perfusion scintigraphy had pooled sensitivity of 0.69 (95% CI, 0.48-0.85) and specificity of 0.77 (95% CI, 0.59-0.89). Head-to-head comparison of dobutamine stress echocardiography and myocardial perfusion scintigraphy (2 studies; 116 participants) showed that dobutamine stress echocardiography had higher specificity and at least equivalent or higher sensitivity. Indirect comparison suggested dobutamine stress echocardiography may have improved accuracy over myocardial perfusion scintigraphy (P = 0.07). Limitations Power to detect differences in accuracy between tests is limited due to sparse data. Absence of significant coronary artery disease may not necessarily correlate with Cardiac event–free survival after transplant. Conclusions Dobutamine stress echocardiography may perform better than myocardial perfusion scintigraphy; however, additional studies directly comparing dobutamine stress echocardiography and myocardial perfusion scintigraphy are needed. Further research should focus on assessing the ability of functional tests to predict postoperative outcome.
Rita F Redberg - One of the best experts on this subject based on the ideXlab platform.
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early noninvasive Cardiac Testing after emergency department evaluation for suspected acute coronary syndrome
JAMA Internal Medicine, 2020Co-Authors: Aniket A Kawatkar, Adam L Sharp, Aileen Baecker, Shaw Natsui, Rita F Redberg, Mingsum Lee, Maros Ferencik, Ernest Shen, Chengyi Zheng, Visanee V MusigdilokAbstract:Importance Professional guidelines recommend noninvasive Cardiac Testing (NIT) within 72 hours of an emergency department (ED) evaluation for suspected acute coronary syndrome. However, there is inexact evidence that this strategy reduces the risk of future death or acute myocardial infarction (MI). Objective To evaluate the effectiveness of early NIT in reducing the risk of death or acute MI within 30 days. Design, Setting, and Participants This retrospective, multicenter cohort study within the Kaiser Permanente Southern California integrated health care delivery system compared the effectiveness of early noninvasive Cardiac Testing vs no Testing in patients with chest pain and in whom acute MI was ruled out who presented to an ED from January 2015 to December 2017. Patients were followed up for up to 30 days after emergency department discharge. Exposures Noninvasive Cardiac Testing performed within 3 days of an ED evaluation for suspected acute coronary syndrome. Main Outcomes and Measures The primary outcome was composite risk of death or acute MI, within 30 days of an ED discharge. Results A total of 79 040 patients were evaluated in this study, of whom 57.7% were female. The mean (SD) age of the cohort was 57 (16) years, and 16 164 patients (21%) had completed early NIT. The absolute risk of death or MI within 30 days was low (<1%). Early NIT had the minor benefit of reducing the absolute composite risk of death or MI (0.4% [95% CI, -0.6% to -0.3%]), and, separately, of death (0.2% [95% CI, -0.2% to -0.1%]), MI (-0.3% [95% CI, -0.5% to -0.1%]), and major adverse Cardiac event (-0.5% [95% CI, -0.7% to -0.3%]). The number needed to treat was 250 to avoid 1 death or MI, 500 to avoid 1 death, 333 to avoid 1 MI, and 200 to avoid 1 major adverse cardiovascular event within 30 days. Subgroup analysis revealed a number needed to treat of 14 to avoid 1 death or MI in the subset of patients with elevated troponin. Conclusions and Relevance Early NIT was associated with a small decrease in the risk of death or MI in patients admitted to the ED with suspected acute coronary syndrome, but this clinical strategy may not be optimal for most patients given the large number needed to treat.
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Abstract 11855: Coronary Computed Tomography Angiography Increases Invasive Procedures Without Improving Clinical Outcomes in Patients With Suspected Acute Coronary Syndrome - A Meta-analysis of Randomized Controlled Trials
Circulation, 2016Co-Authors: Andrew Foy, Sanket S. Dhruva, John Mandrola, Daniel J. Morgan, Rita F RedbergAbstract:Introduction: Coronary computed tomography angiography (CCTA) is considered equal to other forms of noninvasive Cardiac Testing for low-to-intermediate risk patients with suspected ACS. Clinical tr...
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Current Economic Evidence Using Noninvasive Cardiac Testing
2003Co-Authors: Leslee J. Shaw, Rita F Redberg, Charles DenhamAbstract:Over the past few decades, encumbered health care resources have created an ever-increasing societal burden. The continual rise in health care costs often exceeds that of inflation, accounting for approximately 13–16% of the US gross domestic product (GDP) (1). In the United States, recent estimates of the total expenditures for cardiovascular disease approach $300 billion annually (2), 14% of which is the costs for private payers and approximately 33% of which is Medicare costs. Furthermore, annual rates of exercise Testing approach 12 million patients, half of which are performed with Cardiac imaging (including ultrasound, nuclear, magnetic resonance, and positron emission tomographic imaging). Figure 1 depicts recent data from the American College of Cardiology (ACC) on reimbursement for varying subspecialties within cardiology (e.g., Cardiac imaging procedures) (2). Since 1998, nuclear cardiology and echocardiographic procedures encumber approximately 10 and 18%, respectively, of allowable Medicare reimbursements. Current data suggest that Cardiac imaging procedures are growing at a rate of approximately 10% annually, with the largest growth sector being hospital outpatient setting as a result of recent changes in reimbursement that focus on cost containment in that area (e.g., Hospital Out-patient Prospective Payment System [HOPPS]).
John T Nagurney - One of the best experts on this subject based on the ideXlab platform.
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high sensitivity Cardiac troponin i as a gatekeeper for coronary computed tomography angiography and stress Testing in patients with acute chest pain
Clinical Chemistry, 2017Co-Authors: Maros Ferencik, Thomas Mayrhofer, Pamela K Woodard, Quynh A Truong, Frank W Peacock, Fabian Bamberg, Benjamin C Sun, Jerome L Fleg, John T NagurneyAbstract:BACKGROUND: Most patients presenting to the emergency department (ED) with suspected acute coronary syndrome (ACS) undergo noninvasive Cardiac Testing with a low diagnostic yield. We determined whether a combination of high-sensitivity Cardiac troponin I (hs-cTnI) and cardiovascular risk factors might improve selection of patients for Cardiac Testing. METHODS: We included patients from the Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography (ROMICAT) I and II trials who presented to the ED with acute chest pain and were referred for Cardiac Testing. Based on serial hs-cTnI measurements and cardiovascular risk factors, we derived and validated the criterion for no need of Cardiac Testing. We predicted the effect of this criterion on the effectiveness of patient management. RESULTS: A combination of baseline hs-cTnI ( CONCLUSIONS: We derived and validated a criterion for combined hs-cTnI and cardiovascular risk factors that identified acute chest pain patients with no need for Cardiac Testing and could improve effectiveness of patient management. ClinicalTrials.gov Identifiers: NCT00990262 and NCT01084239
Louis W. Wang - One of the best experts on this subject based on the ideXlab platform.
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Cardiac Testing for coronary artery disease in potential kidney transplant recipients
Nephrology, 2012Co-Authors: Louis W. Wang, Magid Fahim, Andrew Hayen, Ruth L. Mitchell, Laura A. Baines, Stephen R. Lord, Jonathan C. Craig, Angela C WebsterAbstract:Dobutamine stress echocardiography [pooled sensitivity 0.79, 95% CI 0.67 to 0.88, pooled specificity 0.89, 95% CI 0.81 to 0.94] and myocardial perfusion scintigraphy [pooled sensitivity 0.74, 95% CI 0.54 to 0.87, pooled specificity 0.70, 95% CI 0.51 to 0.84] had moderate sensitivity and specificity in detecting coronary artery disease. There was evidence that Dobutamine stress echocardiography had improved accuracy over myocardial perfusion scintigraphy (P = 0.02) when all studies were included in the analysis, but this was not significant when we excluded studies of poorer methodological quality, or which defined significant coronary disease using a higher threshold of 70% stenosis (P = 0.09).
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The Cochrane Library - Cardiac Testing for coronary artery disease in potential kidney transplant recipients
Nephrology (Carlton Vic.), 2012Co-Authors: Louis W. Wang, Magid Fahim, Andrew Hayen, Ruth L. Mitchell, Laura A. Baines, Stephen R. Lord, Jonathan C. Craig, Angela C WebsterAbstract:Dobutamine stress echocardiography [pooled sensitivity 0.79, 95% CI 0.67 to 0.88, pooled specificity 0.89, 95% CI 0.81 to 0.94] and myocardial perfusion scintigraphy [pooled sensitivity 0.74, 95% CI 0.54 to 0.87, pooled specificity 0.70, 95% CI 0.51 to 0.84] had moderate sensitivity and specificity in detecting coronary artery disease. There was evidence that Dobutamine stress echocardiography had improved accuracy over myocardial perfusion scintigraphy (P = 0.02) when all studies were included in the analysis, but this was not significant when we excluded studies of poorer methodological quality, or which defined significant coronary disease using a higher threshold of 70% stenosis (P = 0.09).
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Cardiac Testing for coronary artery disease in potential kidney transplant recipients.
The Cochrane database of systematic reviews, 2011Co-Authors: Louis W. Wang, Magid Fahim, Andrew Hayen, Ruth L. Mitchell, Laura A. Baines, Stephen R. Lord, Jonathan C. Craig, Angela C WebsterAbstract:Background Patients with chronic kidney disease (CKD) are at increased risk of coronary artery disease (CAD) and adverse Cardiac events. Screening for CAD is therefore an important part of preoperative evaluation for kidney transplant candidates. There is significant interest in the role of non-invasive Cardiac investigations and their ability to identify patients at high risk of CAD. Objectives We investigated the accuracy of non-invasive Cardiac screening tests compared with coronary angiography to detect CAD in patients who are potential kidney transplant recipients. Search methods MEDLINE and EMBASE searches (inception to November 2010) were performed to identify studies that assessed the diagnostic accuracy of non-invasive screening tests, using coronary angiography as the reference standard. We also conducted citation tracking via Web of Science and handsearched reference lists of identified primary studies and review articles. Selection criteria We included in this review all diagnostic cross sectional, cohort and randomised studies of test accuracy that compared the results of any Cardiac test with coronary angiography (the reference standard) relating to patients considered as potential candidates for kidney transplantation or kidney-pancreas transplantation at the time diagnostic tests were performed. Data collection and analysis We used a hierarchical modelling strategy to produce summary receiver operating characteristic (SROC) curves, and pooled estimates of sensitivity and specificity. Sensitivity analyses to determine test accuracy were performed if only studies that had full verification or applied a threshold of ≥ 70% stenosis on coronary angiography for the diagnosis of significant CAD were included. Main results The following screening investigations included in the meta-analysis were: dobutamine stress echocardiography (DSE) (13 studies), myocardial perfusion scintigraphy (MPS) (nine studies), echocardiography (three studies), exercise stress electrocardiography (two studies), resting electrocardiography (three studies), and one study each of electron beam computed tomography (EBCT), exercise ventriculography, carotid intimal media thickness (CIMT) and digital subtraction fluorography (DSF). Sufficient studies were present to allow hierarchical summary receiver operating characteristic (HSROC) analysis for DSE and MPS. When including all available studies, both DSE and MPS had moderate sensitivity and specificity in detecting coronary artery stenosis in patients who are kidney transplant candidates [DSE (13 studies) - pooled sensitivity 0.79 (95% CI 0.67 to 0.88), pooled specificity 0.89 (95% CI 0.81 to 0.94); MPS (nine studies) - pooled sensitivity 0.74 (95% CI 0.54 to 0.87), pooled specificity 0.70 (95% CI 0.51 to 0.84)]. When limiting to studies which defined coronary artery stenosis using a reference threshold of ≥ 70% stenosis on coronary angiography, there was little change in these pooled estimates of accuracy [DSE (9 studies) - pooled sensitivity 0.76 (95% CI 0.60 to 0.87), specificity 0.88 (95% CI 0.78 to 0.94); MPS (7 studies) - pooled sensitivity 0.67 (95% CI 0.48 to 0.82), pooled specificity 0.77 (95% CI 0.61 to 0.88)]. There was evidence that DSE had improved accuracy over MPS (P = 0.02) when all studies were included in the analysis, but this was not significant when we excluded studies which did not avoid partial verification or use a reference standard threshold of ≥70% stenosis (P = 0.09). Authors' conclusions DSE may perform better than MPS but additional studies directly comparing these Cardiac screening tests are needed. Absence of significant CAD may not necessarily correlate with Cardiac-event free survival following transplantation. Further research should focus on assessing the ability of functional tests to predict postoperative outcome.
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Cardiac Testing for coronary artery disease in potential kidney transplant recipients a systematic review of test accuracy studies
American Journal of Kidney Diseases, 2011Co-Authors: Louis W. Wang, Magid Fahim, Andrew Hayen, Ruth L. Mitchell, Laura A. Baines, Jonathan C. Craig, Angela C Webster, S W LordAbstract:Background Cardiovascular disease is the leading cause of death after kidney transplant. Screening for coronary artery disease is integral to pretransplant evaluation, although the relative performance of different tests is uncertain. Study Design Systematic review of diagnostic test accuracy studies using hierarchical summary receiver operating characteristic analysis. Setting & Population Kidney transplant candidates undergoing pretransplant assessment. Selection Criteria of Studies Studies evaluating the accuracy of screening tests for detecting coronary artery disease. Index Tests Any non- or minimally invasive test used to diagnose coronary artery disease. Reference Test Coronary angiography. Results 11 studies (690 participants) evaluated dobutamine stress echocardiography; 7 (317 participants), myocardial perfusion scintigraphy; 2 (129 participants), exercise stress electrocardiography; and 2 (121 participants), other tests. Dobutamine stress echocardiography had pooled sensitivity of 0.80 (95% CI, 0.64-0.90) and specificity of 0.89 (95% CI, 0.79-0.94). Myocardial perfusion scintigraphy had pooled sensitivity of 0.69 (95% CI, 0.48-0.85) and specificity of 0.77 (95% CI, 0.59-0.89). Head-to-head comparison of dobutamine stress echocardiography and myocardial perfusion scintigraphy (2 studies; 116 participants) showed that dobutamine stress echocardiography had higher specificity and at least equivalent or higher sensitivity. Indirect comparison suggested dobutamine stress echocardiography may have improved accuracy over myocardial perfusion scintigraphy (P = 0.07). Limitations Power to detect differences in accuracy between tests is limited due to sparse data. Absence of significant coronary artery disease may not necessarily correlate with Cardiac event–free survival after transplant. Conclusions Dobutamine stress echocardiography may perform better than myocardial perfusion scintigraphy; however, additional studies directly comparing dobutamine stress echocardiography and myocardial perfusion scintigraphy are needed. Further research should focus on assessing the ability of functional tests to predict postoperative outcome.