July 22, 1974

The Diagnostic Tripod

JAMA. 1974;229(4):459. doi:10.1001/jama.1974.03230420071035

When a patient with angina exhibits characteristic S-T depressions on the electrocardiogram and evidence of vessel obstruction on the coronary angiogram, the diagnosis of coronary heart disease is not in doubt. Yet, what if the clinical, electrophysiologic, and roentgenographic findings are discordant? What if the ECG is normal and the arteriogram is not, or vice versa? What if both are normal, but the patient continues to have incapacitating chest pain?

It would appear that the three diagnostic criteria do not carry equal measures of importance. Pain, being subjective, receives the least weight. True, patients were known to suffer acute myocardial infarction shortly after being cleared by objective evidence. They were, however, considered exceptions to the general rule.

An abnormal exercise ECG is taken more seriously. Before the advent of coronary angiography, positive results from a Master step test or a treadmill exercise test could make the difference between a diagnosis