Burgstahler and Nieß criticize the fact that the studies we cited in our article on the prevalence of coronary heart disease (CHD) in general practice have methodological weaknesses. They assume that the actual prevalence is much higher than the 8–11% we cited. We wish to counter that by pointing out that the cited studies represent the best available evidence. In both studies, a delayed type reference standard in association with an independent panel of experts was used to define the diagnosis. The defined characteristics ensured validity, transparency, and reproducibility of the diagnosis (stringent and standardized follow-up of all participants for 6 months, assessment by an independent expert panel, etc). This type of method can be considered as adequate if, for example, not all patients can be invasively diagnosed, for ethical reasons (1, 2).

Burgstahler and Nieß further criticize that additional parameters that were collected in the context of ergometry testing (among others, performance ability, blood pressure behaviors, lactate) were not mentioned. Our counter-argument is that the possible prognostic use of the exercise electrocardiogram (ECG), including possible lactate testing, is undisputed, but it was not the subject of our article (3). We focused on the use of exercise ECGs in diagnosing stenosing CHD on the basis of a pathological depression of the ST segment. Furthermore, we focused on pure ergometry, as is conducted in general practice and specialty practice. In special patient populations and with extended options, ergometry is undoubtedly a method that has greater meaningfulness.

Wollmann sees a problem in the Marburg Heart Score (MHS), in that it deviates in some points from what is shown in Table 2 (“pretest probability...”). We wish to point out that the MHS serves to assess the clinical probability of CHD at the general practice level, but that Table 2 shows criteria to assess the pretest probability at the level of specialist cardiology practice. The patient populations are different. Expert opinion (4) and empirical findings (5) are a reminder that the meaningfulness of diagnostic tests can vary across different aspects of clinical practice.

He furthermore criticizes our cautious wording: “When interpreting these score results, it is important to take the overall clinical picture into account.” We would point out that considering the overall clinical picture is indicated in the interpretation of every and any diagnostic test. And in the case of clinical decision rules (such as the MHS), the risk of certain automatisms is even higher than in other diagnostic tests.

With regard to his comment, that in many places it is easier to obtain an appointment for cardiac catheterization than for ergometry, we wish to remind readers that we did mention non-invasive tests (among others, myocardial SPECT [single photon emission computed tomography], exercise echocardiography) (3). Both tests are included in the repertoire of services covered by the statutory health insurers and are available nationwide in Germany. For this reason, it is possible to implement our diagnostic algorithm within acceptable waiting periods.

DOI: 10.3238/arztebl.2018.0131c

Prof. Dr. med. Christian Albus
Klinik und Poliklinik für Psychosomatik und Psychotherapie,
Universitätsklinikum Köln
Christian.albus@uk-koeln.de

Prof. Dr. med. Jörg Barkhausen
Klinik für Radiologie und Nuklearmedizin,
Universitätsklinikum Schleswig-Holstein – Campus Lübeck

Prof. Dr. med. Eckart Fleck
Innere Medizin/Kardiologie,
Deutsche Gesellschaft für Kardiologie,
Hauptstadtbüro DGK, Berlin

Dr. rer. medic. Jörg Haasenritter, M. Sc. N., Dipl. Pflegewirt (FH)
Philipps-Universität Marburg, Abteilung für Allgemeinmedizin,
Präventive und Rehabilitative Medizin, Marburg

Prof. Dr. med. Oliver Lindner
Institut für Radiologie, Nuklearmedizin und molekulare Bildgebung,
Herz- und Diabeteszentrum NRW, Bad Oeynhausen

Prof. Dr. med. Sigmund Silber
Kardiologische Praxis, München

Conflict of interest statement
Prof. Lindner has received lecture fees from GE Healthcare, Casionpharm, and Mediso.

Prof. Albus is receiving honoraria for an authorship related to the topic from Elsevier-Verlag, Deutscher Ärzteverlag, and Schattauer-Verlag. He has received fees for scientific lectures from Daiichi-Sankyo, WebMD Germany, KelCON GmbH, PCO Tyrol Kongress, and MSD.

Prof. Barkhausen has received lecture fees from Bayer and Philips.

Prof. Silber, Prof. Fleck and Dr. Haasenritter declare no conflict of interest.

1.
Knottnerus JA, Muris JW: Assessment of the accuracy of diagnostic tests: the cross-sectional study. In: Knottnerus JA, Buntinx F (eds.): The evidence base of clinical diagnosis: theory and methods of diagnostic research. Oxford and Hoboken NJ: Wiley-Blackwell Pub/BMJ Books 2009: 42–63.
2.
Reitsma JB, Rutjes AWS, Khan KS, Coomarasamy A, Bossuyt PM: A review of solutions for diagnostic accuracy studies with an imperfect or missing reference standard. J Clin Epidemiol 2009; 62: 797–806 CrossRef MEDLINE
3.
Albus C, Barkhausen J, Fleck E, Haasenritter J, Lindner O, Silber S on behalf of the German National Disease Management Guideline “Chronic CHD” development group: Clinical practice guideline: The diagnosis of chronic coronary heart disease. Dtsch Arztebl Int 2017; 114: 712–9 VOLLTEXT
4.
Leeflang MM, Bossuyt PM, Irwig L: Diagnostic test accuracy may vary with prevalence. Implications for evidence-based diagnosis. J Clin Epidemiol 2009; 62: 5–12 CrossRef MEDLINE
5.
Schneider A, Ay M, Faderl B, Linde K, Wagenpfeil S: Diagnostic accuracy of clinical symptoms in obstructive airway diseases varied within different health care sectors. J Clin Epidemiol 2012; 65: 846–54 CrossRef MEDLINE
1. Knottnerus JA, Muris JW: Assessment of the accuracy of diagnostic tests: the cross-sectional study. In: Knottnerus JA, Buntinx F (eds.): The evidence base of clinical diagnosis: theory and methods of diagnostic research. Oxford and Hoboken NJ: Wiley-Blackwell Pub/BMJ Books 2009: 42–63.
2.Reitsma JB, Rutjes AWS, Khan KS, Coomarasamy A, Bossuyt PM: A review of solutions for diagnostic accuracy studies with an imperfect or missing reference standard. J Clin Epidemiol 2009; 62: 797–806 CrossRef MEDLINE
3.Albus C, Barkhausen J, Fleck E, Haasenritter J, Lindner O, Silber S on behalf of the German National Disease Management Guideline “Chronic CHD” development group: Clinical practice guideline: The diagnosis of chronic coronary heart disease. Dtsch Arztebl Int 2017; 114: 712–9 VOLLTEXT
4. Leeflang MM, Bossuyt PM, Irwig L: Diagnostic test accuracy may vary with prevalence. Implications for evidence-based diagnosis. J Clin Epidemiol 2009; 62: 5–12 CrossRef MEDLINE
5.Schneider A, Ay M, Faderl B, Linde K, Wagenpfeil S: Diagnostic accuracy of clinical symptoms in obstructive airway diseases varied within different health care sectors. J Clin Epidemiol 2012; 65: 846–54 CrossRef MEDLINE

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