A Comparative Study of Different Treadmill Scores to Diagnose Coronary Artery Disease Among Patients Attending Bangabandhu Sheikh Mujib Medical University
Conditions: Stable Ischemic Heart Disease
Sponsor: Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

1 
 
 
A comparative study of different treadmill scores to diagnose  
Coronary Artery Disease among patients attending  
Bangabandhu Sheikh Mujib Medical University 
 
 
 
NCT no:    02879032 
 
 
Date of document: 16th November, 2016 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

2 
 
1. Title of the study: A comparative study of different treadmill scores to diagnose Coronary Artery 
Disease among patients attending Bangabandhu Sheikh Mujib Medical University. 
 
 
2. Principle Investigator (PI) 
:Dr. Md. Mashiul Alam 
 
  MD (Cardiology), Phase –B Student, 
 
  Department of Cardiology 
 
 
3. Name of the present course 
: MD (Cardiology), Residency 
4. Joining date in Phase B 
: September, 2015 
5. Name of the Institute 
: Bangabandhu Sheikh Mujib Medical University 
 
6. Expected date of examination 
: July, 2018 
7. Guide 
: Dr. Md. MukhlesurRahman 
 
  Associate Professor, Department of Cardioloy 
8. Co-Investigator/ Co- Guide 
: Dr. TanjimaParvin 
 
  Associate Professor, Department of Cardiology 
9. Place of Study 
: Department of Cardiology, BSMMU, Shahbag, Dhaka 
10. Type of study 
: Cross-sectional study 
11. Duration of study 
: August 2016 to July 2017 
12. Total cost 
: Tk-42,500 ⁄= 
 
   (Forty two thousand five hundred taka only) 
13. Funding agency 
: Department of Cardiology and Investigator 
We agree to obtain approval of the Institutional Review Board of BSMMU for any changes 
involving the rights and welfare of subject or any changes of the methodology before making any 
such changes. 
Principle Investigator 
 
 
 
 
 
Guide 
Dr. Md. Mashiul Alam 
 
 
 
 
Dr. Md. MukhlesurRahman 
MD(Cardiology), Phase B Student  
 
 
Associate Professor 
Department of Cardiology  
 
 
 
Department of Cardiology 
University Cardiac Center, BSMMU 
 
 
University Cardiac Center,BSMMU 
 
 
 
 
 
 
 
 
 

3 
 
Date:  24/09/2016 
 
To 
The Chairman  
Department of Cardiology 
University Cardiac Center, BSMMU 
Shahbag, Dhaka -1000 
 
Sub: For permission of thesis work to be carried out in Department of Cardiology. 
 
Sir, 
With due respect and honor, I am a MD (phase-B) student in Cardiology, would like to seek your kind 
consideration about the thesis work to be carried out in the department of cardiology. My protocol was 
approved by our Departmental Academic and Thesis Committee and recommended for your kind 
consideration. My Supervisor has agreed to supervise and monitor my work regularly and communicate 
with you if needed. 
 
Sincerely yours, 
 
 
Dr. Md. Mashiul Alam 
MD (Cardiology), Phase-B                   
Department of Cardiology 
University Cardiac Center 
BSMMU, Shahbag, Dhaka-1000 
 
 
 

4 
 
Date:  24/09/2016 
 
To 
The Pro-Vice Chancellor (Academic) and Chairman  
Institutional Review Board of BSMMU 
Shahbagh, Dhaka-1000 
 
Sub: For permission of thesis work to be carried out in the Department of Cardiology, by  
Dr. Md. Mashiul Alam, MD (Phase-B) student. 
 
Sir, 
With due respect and honor, I would like to seek your kind consideration about the thesis work to be 
carried out by Dr. Md. Mashiul Alam, MD (Phase-B) student. His protocol was approved by our 
Departmental Academic and Thesis Committee and recommended for your kind Consideration. 
Supervisor has agreed to supervise and monitor his work regularly and communicate with you if needed 
during the work. 
 
Thanking you, 
 
Professor (Dr.) Sajal Krishna Banerjee  
Chairman & Professor  
Department of Cardiology 
University Cardiac Center 
BSMMU, Shahbagh, Dhaka  
 
 
 

5 
 
Date:  24/09/2016  
To 
The Pro-Vice Chancellor (Academic) and Chairman  
Institutional Review Board of BSMMU 
Shahbagh, Dhaka-1000 
 
Sub: For permission of thesis work to be carried out in Department of Cardiology by 
Dr. Md. Mashiul Alam, MD (Phase-B) student. 
 
Sir, 
With due respect and honor, I would like to seek your kind consideration about the thesis work to be 
carried out by Dr. Md. Mashiul Alam, MD (Phase-B) student. His protocol was approved by our 
Departmental Academic and Thesis Committee and recommended for your kind consideration. I have 
agreed to supervise and monitor his work regularly and communicate with you if needed during the work. 
 
With regards, 
Guide 
Dr. Md.MukhlesurRahman 
Associate Professor 
Department of Cardiology 
University Cardiac Center 
BSMMU, Shahbagh, Dhaka-1000 
 
 
 
 
 

6 
 
Date:  24/09/2016 
 
To 
The Pro-Vice Chancellor (Academic) and Chairman  
Institutional Review Board of BSMMU 
Shahbagh, Dhaka -1000 
 
Sub: For permission of thesis work to be carried out in Department of Cardiology. 
 
Sir, 
With due respect and honor, I am an MD (phase-B) student in Cardiology, would like to seek your kind 
consideration about the thesis work to be carried out in Cardiology department. My protocol was 
approved by our Departmental Academic and Thesis Committee and recommended for your kind 
consideration. My Supervisor has agreed to supervise and monitor my work regularly and communicate 
with you if needed. 
 
 
Sincerely yours, 
 
Principle Investigator 
Dr. Md. Mashiul Alam 
MD (Cardiology), Phase-B                   
Department of Cardiology 
University Cardiac Center 
BSMMU, Shahbag, Dhaka-1000 
 
 

7 
 
Abstract for IRB 
Background:Exercise treadmill test (ETT) is frequently done, inexpensive, relatively safe 
investigation for diagnosis of ischemic heart disease and prediction of exercise capacity. 
Ischemic heart disease is increasing by leaps and bounds all over the world even in the 
developing countries like Bangladesh. The incidence rate of coronary artery disease is not 
limited to male gender as previously seen. As a cause of industrialization and increased life 
expectancy, incidence of ischemic heart disease in females is escalating now in Bangladesh 
also. Though ETT is a well accepted investigation to diagnose Coronary Artery Disease 
(CAD), it has a high false positive and false negative result if ST segment response alone is 
calculated for interpretation of the test.  
Rationale: Duke Treadmill Score (DTS) and Simple Treadmill Score (STS) are valid and 
well known scores which can predict coronary artery disease burden more efficiently than ST 
segment response alone. Computer generated Cleveland clinic score (CCS) is another valid 
treadmill score which has a complex algorithm but effective way to predict 3 year and 5 year 
survivability. These three scores are well tested on western population but to our best 
knowledge there is little or no information regarding their predictability of CAD. It’s well 
known that ETT has a high false positive result in our population, so applying the scores may 
render ETT more efficient and abrogate unwanted risk of undergoing coronary angiography 
to diagnose CAD, especially in females.  
Objective: To identify difference of predictability of DTS, STS and CCS to diagnose 
significant CAD by Coronary Angiography (CAG). 
Method: A Cross-Sectional study will be carried out on patients attending University Cardiac 
Center in Bangabandhu Sheikh Mujib Medical University (BSMMU) for stable chest pain to 
find out the accuracy of commonly applied treadmill scores (DTS, STS) and ST segment 
response to diagnose CAD as well as accuracy of computer generated Cleveland Clinic Score 
will be tested. Total 102 people including male and female who have undergone ETT will be 
included according to inclusion and exclusion criteria and informed written consent will be 
taken. Treadmill scores will be calculated. The patients who have undergone exercise 
treadmill test for provocable ischemia and have their coronary angiogram done for 
confirmation and identification of coronary artery lesion according to the recommended 
guideline for CAG with-in 6 months will be selected. All available data will be analyzed 
using SPSS. The accuracy of different scores will be calculated and compared with each 
other. According to currently available data from studies in western population we predict the 
treadmill scores will have good predictability and will be efficient to control unwanted CAG 
procedure to diagnose CAD. 

8 
 
 
Declaration 
We the undersigned solemnly declare and affirm that the research protocol entitled “A 
comparative study of different treadmill scores to diagnose coronary artery disease in a 
tertiary care hospital”has been developed by the under mentioned Principal Investigator (PI), 
Phase B student of MD Cardiology at the Department of Cardiology, University Cardiac Center, 
Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka with the active guidance and 
supervision of his guide whose names are listed below. The concepts and methods underlying the 
research protocol are based on the original ideas developed by the PI who shall carry out the work 
and present the results as a thesis as an academic requirement for the degree being pursued by the 
student at the university. 
The PI has developed this protocol following all ethical guidelines and principal for the protection 
of rights of human and children involved in biomedical research, including Helsinki Declaration, 
NIH GCP, and WHO. No part of the contents of this protocol has been published in any form nor 
submitted for publication in any media; it does not contain any printed and copyrighted material 
reproduced from available sources without permission of the copyright owner. 
The protocol has been presented by the student in the department and categorically reviewed, 
revised, and approved by the assigned departmental supervisors and guides.We believe this 
protocol is likely to generate new information to fill in the existing knowledge gap leading to a 
productive and useful conclusion in the field of study. 
We would highly appreciate if the protocol is reviewed and approved by the BSMMU IRB for 
immediate implementation. 
 
 
---------------------------------               -------------------------------------        -------------------------------- 
Principal investigator                               Supervisor                  Chairman and Dept.Head 
Dr. Md. Mashiul Alam               Dr. Md. MukhlesurRahmanProf. (Dr.) Sajal Krishna Banerjee  
MD (Cardiology), Phase-B            Associate Professor              Chairman & Professor  
Department of Cardiology            Department of Cardiology      Department of Cardiology 
University Cardiac Center          University Cardiac Center      University Cardiac Center 
BSMMU, Shahbagh, Dhaka      BSMMU, Shahbagh, Dhaka     BSMMU, Shahbagh, Dhaka  
Mobile No-01786337788           Mobile No-01819238868           Mobile No-01711594017 
Date:                                            Date:                                            Date: 
 

9 
 
IRB Check List for Study Population (List A) 
(Please tick mark against your appropriate answers for all the statements below, write NA if not 
applicable)   
1.Source of study population 
 
7. Does the study require: 
 
a. 
Sick persons 
b. Healthy persons 
c. 
Minors 
or 
persons 
under 
guardianship 
Yes   /   No 
Yes   /   No 
Yes   /   No 
a. 
Use of records (hospital, medical, 
death, birth, lab reports, or others). 
Yes   /   No 
b. Use of fetal tissue or abortus. 
Yes   /   No 
c. 
Use 
of 
organs 
or 
body 
fluids(serum, blood, CSF, sputum, 
urine, stool, pus, tears, amniotic 
fluid etc). 
Yes   /  No 
2. Age Groups of participants 
 
8. Are subjects clearly informed 
about: 
 
a. 
0-4 years 
b.    5-10 years 
c.    11-17 years 
d.    18-64 years 
e.     65+ years 
Yes   /   No 
Yes   /   No 
Yes   /   No 
Yes   /   No 
Yes   /   No 
a. 
Nature and purpose of study. 
Yes   /   No 
b.     Procedures to be followed 
including alternatives used. 
Yes   /   No 
c.    Physical risks. 
Yes   /   No 
d.    Mental Risks. 
Yes   /   No 
e.     Private questions. 
Yes   /   No 
3  Gender Groups 
 
f      Benefits to be derived. 
Yes   /   No 
a. 
Male 
b. Female 
c. 
Transgender 
Yes   /   No 
Yes   /   No 
Yes   /  No 
g.    Right to refuse to participate 
or to withdraw from the study. 
Yes   /   No 
h.    Confidential handling of data. 
Yes   /   No 
i.      Compensation (where there 
        are risks or loss of working 
        hours or privacy is involved 
in any particular procedure). 
Yes  /    No 
4. Does the study involve special 
groups as listed below ? 
 
9. Signed informed consent form will 
be obtained from subjects before 
admission in to the study. 
 
a. 
Pregnant women 
b. Fetusin utero 
c. 
Prisoners 
d. Mentally impaired 
e. 
Sex workers/ drug addicts 
f. 
Refugee/ tribal groups 
5. Physical Risks: 
a.  Physical risks including 
venipuncture, x-ray, skin test 
d. Social risks 
e. 
Psychological risks 
f. 
Discomfort to subject 
g. Invasion of body 
h. Invasion of privacy 
i. 
Disclosure of information 
damaging to subjects or 
others 
Yes   /   No 
Yes   /   No 
Yes   /   No 
Yes   /   No 
Yes   /   No 
Yes   /   No 
 
Yes   /   No 
 
Yes   /   No 
Yes   /   No 
Yes   /   No 
Yes   /   No 
Yes   /   No 
Yes   /   No 
 
a. 
From patients, if adults, >18 y 
Yes   /   No 
b. From parents or guardians if  
patients  are minors, < 18 y. 
Yes   /   No 
10. Will precaution be taken to 
protect anonymity of subjects ? 
Yes   /   No 
11. Does the study involve: 
 
a. 
Human exposure to radiation ? 
Yes   /   No 
b. Investigational new drug or  device. 
Yes   /   No 
c. Human exposure to infectious,toxic, 
and other harmful agents. 
Yes   /   No 
d. New treatment regimen. 
Yes   /   No 
e. Observation of public behavior. 
Yes   /   No 
12. 
Does 
the 
study 
population 
require the following groups ? 
 
a. 
Healthy volunteers. 
Yes   /   No 
b. Healthy control groups 
Yes   /   No 
5. Project/ study site 
 
c. 
Untreated or ‘placebo’ groups. 
Yes   /   No 
a. 
BSMMU Hospital 
b. Urban Community 
c. 
Rural Community 
d. Other hospitals 
Yes   /   No 
Yes   /   No 
Yes   /  No 
Yes   /  No 
d. Invasive tests on healthy subjects 
to assess “normal” values in 
population. 
Yes   /   No 
13. Describe what type of study 
 
a. 
Cross-sectional study 
Yes   /   No 
b. Cohort, longitudinal study 
Yes   /   No 
 
 
c. 
Controlled Clinical Trial 
Yes   /   No 
 
 

10 
 
 
IRB Check List B 
1. 
Trial Registration 
(a) Has the trial been registered with any registration authority?         Yes   /   No 
(b) If yes, please provide full information including registration number, date of registration, and 
organization. 
 
 
 
 
 
 
 
 
2. 
Dissemination plan 
Please describe the anticipated plan for disseminating the results of the study when completed. 
 
 
 
 
 
 
 
 
3. 
Conflicts of interests: Yes   /   No 
If yes, please describe any conflicts of interests involved or anticipated in the study. 
 
4. 
Investigator’s Certification:Has the PI successfully completed the NIH clinical 
investigator’s qualifying exam online?     Yes   /   No 
 
 
 
 
 
5. 
Expected Outcome:What will be the expected outcome of the study if successfully 
completed. 
 
 
 
 
 
a. 
Organization 
name 
& 
address:
 
b. Registration number: NCT02879032     C. Date of Registration: 24th August, 2016 
Results will be presented as (check as many apply): 
a. 
Thesis 
b. Dissertation 
c. 
Journal publication 
d. Seminar at the university and international workshop/conference. 
e. 
Internal report 
f. 
CONSORT (Consolidated Standards for Reporting Trials)  format has been included 
and will be followed in reporting the trial results when completed. This is required 
mostly for controlled clinical trials. 
NIH Clinical Investigator Exam: 
Completion date: 12th August, 2016 
Certification 
obtained:NIH 
Office 
of 
Clinical 
Research 
Training 
and 
Medical 
Educationcomputer-based Clinical Research Training course. 
The study will be expected to: (Check as many apply). 
a. 
Generate new knowledge. 
b. Confirm existing knowledge.  
c. 
Extend current knowledge to wider field of application.  
d. Reassess known effects of an intervention on BD population. 
e. 
Provide basis for future, definitive studies.  
f. 
Change current diagnostic and therapeutic practice or procedures.  
g. Change current behavior among population.  

11 
 
 
Budget 
 
Instrument or Material 
Unit 
Unit 
Cost 
Total 
estimated 
budget (InTaka) 
1. Cost of investigations 
102 
11400 
(1,162,800/=) 
Patients Self 
expenditure for ETT 
and CAG 
2.Internal work, literature search and 
purchase of article or reference 
paper 
 
- 
 
- 
 
15,000/= 
3.Stationeries, Paper files, staplers 
etc 
- 
 
- 
5000/= 
4.Printing and reproduction 
- 
- 
10,000/= 
5.Thesis writing, computer compose 
etc 
- 
- 
10,000/= 
6.Thesis binding 
- 
- 
1500/= 
7.Miscellaneous 
- 
- 
1000/= 
TOTAL42,500/= 
 
   (In word:Forty two thousand five hundred) 
 
--------------------------------------                       --------------------------- 
Signature of the Investigator            Signature of the Supervisor  
 
 
 
 

12 
 
 
TITLE 
 
A COMPARATIVE STUDY OF DIFFERENT TREADMILL SCORES 
TO 
DIAGNOSE 
CORONARY 
ARTERY 
DISEASE 
AMONG 
PATIENTS 
ATTENDING 
BANGABANDHU 
SHEIKH 
MUJIB 
MEDICAL UNIVERSITY 
 
 
 
Principle Investigator 
Dr. Md. Mashiul Alam 
MD (Cardiology), Phase- B 
Department of Cardiology 
University Cardiac Center 
BSMMU 
 
 
 
Guide 
 
 
 
 
 
 
 
Co-guide 
Dr. Md. MukhlesurRahman 
 
 
 
Dr. TanjimaParvin 
Associate Professor 
 
 
 
 
 
Associate Professor 
Department of Cardiology 
 
 
 
 
Department of Cardiology 
University Cardiac Center 
 
 
 
University Cardiac Center 
BSMMU  
 
 
 
 
 
BSMMU 
 
 

13 
 
 
 
Index 
 
 
 
 
 
 
 
 
 
 
Page no. 
1. Introduction ----------------------------------------------------------------------- 13 
2. Rationale --------------------------------------------------------------------------- 14 
3. Research Question and Objectives ------------------------------------------- 15 
4. Literature Review ---------------------------------------------------------------- 16 
5. Materials and Methods --------------------------------------------------------- 18 
Study design, Study area, Period of study etc 
Sampling Procedure 
6. Inclusion and Exclusion Criteria --------------------------------------------- 19 
7. Procedures during study ------------------------------------------------------- 20 
8. Data Collection and Quality assurance strategy, Ethical issue -------- 21 
9. Sample size calculation --------------------------------------------------------- 22 
10. Statistical Method--------------------------------------------------------------- 23 
11. Dummy tables and Graphs---------------------------------------------------- 24 
12. Operational definitions--------------------------------------------------------- 28 
13. References------------------------------------------------------------------------- 33 
 
Appendices 
Treadmill Scores and their calculation ---------------------------------37 
 
 
Study design flow chart----------------------------------------------------40 
Questionnaire/ Data Collection Form-----------------------------------41 
Informed consent form-----------------------------------------------------43 
Abbreviations----------------------------------------------------------------47 
 
 
 
 

14 
 
Introduction 
At present several treadmill scores have been proposed as means for improving the 
diagnostic accuracy of the exercise treadmill test (ETT) and to predict future risk of 
cardiac events (Berman et al., 1978 & Do et al., 1997). Although a large number of 
noninvasive stress testing modalities are currently available, the exercise ECG is still used 
as a standard for comparison with other clinical and testing risk markers. It is also the 
least costly of all provocative noninvasive tests. The Duke Treadmill Score (DTS), 
traditionally a prognostic score, was recently tested as a diagnostic score and shown to 
predict CAD better than the ST response alone(Shaw et al., 1998). But questions remain 
regarding the diagnostic accuracy of treadmill scores when applied to a different patient 
population; furthermore, many treadmill scores have not been compared with one another 
in the same population(Fearon et al., 2002).To date, no composite stress-test score or 
noninvasive risk index has been shown to provide both accurate diagnostic and prognostic 
risk estimates. Despite that exercise treadmill test remains a useful test for diagnosing 
coronary artery disease (CAD) in patients with chest pain and at intermediate risk for 
CAD (Do et al., 1997).The sensitivity and specificity of ETT varies considerably. 
According to a meta-analysis conducted by Gianrossi et al there was a wide variability in 
sensitivity and specificity of ETT [sensitivity 68± 16% (range 23–100%); specificity 
77±17% (range: 17–100%). Another Meta analysis showed sensitivity of 81± 12% 
(range: 40–100%) and specificity of 66± 16% (range: 17–100%) (Myers et al., 
1994).Fearon WF et al showed sensitivity and specificity was higher when treadmill 
scores were applied in comparison to ST response alone. They used a consensus score 
consisting of  the Morise, Dentrano and VA score and found predictive accuracy of the 
consensus score for stratifying patients to low and high likelihood for CAD was 
significantly higher than the predictive accuracy of  DTS, 80(74-86)% versus 71(65-77)% 
(p< 0.0001). But Fearon WF et al conducted the study only on male population in USA 
and the consensus score was calculated by average of computer generated treadmill 
scores. In 2012 Mao L et al have shown 73 out of 104 male patients were detected CAD 
both by ETT and CAG, the accuracy rate was 70.2% which was much higher than that 
(50.0%) of the female patients (p<0.05) and they only used ST changes alone to 
demonstrate ETT positivity In this study, we will compare the diagnostic accuracy of well 
known prognostic scores namely, Duke Treadmill Score, Simple Treadmill Score and 
Cleveland Clinic Score  to identify significant coronary artery lesion in Bangladeshi male 
and female patients. 

15 
 
 
 
 
Rationale 
 
Though exercise treadmill test has high false positive and negative rates(Zang et al., 
2007) , it is cheap, easily available, less time consuming to the interpret results and its 
accuracy can be increased by  calculating ST/HR index, treadmill score, QT dispersion 
and so on (Kronander 2010 &Dentrano 1989). On the contrary the gold standard test 
coronary angiogram for detecting CAD is expensive, time consuming, potentially 
hazardous with many complications and often the CAG shows normal coronary arteries in 
female population.ST-segment depression and chest pain as the classic criteria for CAD 
diagnosis are well known and accepted. Besides If treadmill score were used the 
diagnostic accuracy of ETT would had been higher. The accuracy of different treadmill 
scores in Bangladeshi population especially the female population is largely unknown. 
Duke Treadmill Score and Simple Treadmill Score are well validated score in western 
population and are used for diagnostic & prognostic interpretation of ETT. The predictive 
accuracy of DTS to diagnose CAD is 71% (Fearon 2002). In 2001 Raxwal V et al. 
showed simple treadmill score has sensitivity of 88% and specificity of 96%. If we 
calculate the accuracy of simple treadmill score using the formula “Accuracy = 
(Sensitivity) x Prevalence + (Specificity) x (1- Prevalence)” it sums up nearly 93% 
according to prevalence of CAD in urban population. Cleveland Clinic Score is a 
prognostic score of ETT. It gives value from which we can predict the probability of 3 
year or 5 year survival. It was shown that it has a very high negative predictive value 
approaching 97%. Besides to the best of our knowledge Cleveland Clinic Score was not 
tested as a diagnostic predictor of CAD and there are few studies regarding treadmill 
scores predictability in Bangladesh. In our study we will use all of these three scores and 
compare their accuracy to predict significant CAD. DTS, Simplified Treadmill Score, and 
Cleveland clinic score can be implemented effectively to identify patients with low 
probability of CAD and excluded from undergoing expensive and potentially hazardous 
CAG if the real scenario of the treadmill scores is known in our population. 
 
 
 

16 
 
 
 
 
Research question 
 
 
Howdo different treadmill scores (Duke Treadmill Score, Simple Treadmill Score, 
Cleveland Clinic Score) vary to predictprobability of Coronary Artery Disease in 
Bangladeshi population in a tertiary care hospital? 
 
 
 
General Objectives 
 
To identify difference of predictability of DTS, Simple Treadmill Score and 
Cleveland Clinic Score to diagnose significant CAD by Coronary Angiography. 
 
 
Specific Objectives 
 
1. 
To estimate accuracy of ST segment response, DTS, Simple Treadmill Score 
and Cleveland Clinic Score to predict CAD. 
2. 
To compare DTS, Simple treadmill score, Cleveland Clinic Score accuracy to 
predict coronary artery disease. 
3. 
To identify the relation of different level of treadmill scores with severity of 
CAD.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

17 
 
 
 
Literature Review 
According to Islam AKMM and Majumder AAS “Coronary artery disease in Bangladesh: 
A review published in 2013 the exact prevalence of CAD in Bangladesh is not known. 
Only a limited number of small-scale epidemiological studies are available. Probably the 
prevalence of IHD was first reported in 1976, which was 0.33%. More recent data 
indicates CAD prevalence between 1.85% and 3.4% in rural and 19.6% in an urban 
sample of working professionals. Despite marked disparity in values, there seems to be a 
rising prevalence of CAD in Bangladesh. 
Gianrossi et al.investigated the diagnostic accuracy of ETT through a meta-analysis 
including 147 published reports involving 24,074 patients who underwent both coronary 
angiography and ETT.There was a wide variability in sensitivity and specificity of ETT 
[sensitivity 68± 16% (range 23–100%); specificity 77±17% (range: 17–100%)]. Another 
Meta analysisshowedsensitivity of 81± 12% (range: 40–100%) and specificity of 66± 
16% (range: 17–100%). 
2014 Taimur et al evaluated ETT (Treadmill) Positive Patients in a Tertiary Care Hospital 
of Bangladesh by doing angiogram subsequently. They found the overall positive 
predictive value of ETT is 77.9%, and for male patient PPV is 86.25% and for female 
patient it is 50%. 
In 1987 Mark DB et al showed Duke Treadmill Score was useful for stratifying prognosis 
in patients with suspected coronary artery disease who were referred for catheterization, 
and may provide a useful adjunct to clinical decision making in the larger population of 
patients being evaluated for chest pain. They had evaluated 2842 patients with chest pain 
who had both treadmill testing and cardiac catheterization. 
Shaw LJ et al in 1998 estimated DTS provides accurate diagnostic and prognostic 
information for the evaluation of symptomatic patients evaluated for clinically suspected 
ischemic heart disease. 
In 2015 Gunaydin et al showed there was a strong negative correlation between DTS and 
Syntax Score (r= - 072, p< 0.001). The area under the receiver-operating curve of DTS 
was 0.83 (0.77-0.88, P < 0.001) for predicting significant presence of CAD. The optimal 
cut-off value of DTS to predict the significant presence of CAD was -3.7 (sensitivity of  
 

18 
 
 
74% and a specificity of 73%).The area under the receiver-operating curve of DTS was 
0.84 (0.78-0.90, P < 0.001) for predicting high SS. The optimal cut-off value of DTS to 
predict high SS was -11.2 (sensitivity of 81% and a specificity of 80%). They 
concluded DTS can predict the presence and severity of stable coronary artery disease 
before coronary angiography and may enable to estimate revascularization method that 
will be required after the procedure. 
Raxwal V, Shetler K, Morise A et al, 2001 developed and validated a simple treadmill 
score for men using 1282 male patients which can be used and calculated without using a 
calculator and the score has a sensitivity of 88% and a specificity of 96%. 
In 2002 a simple score was developed for use specifically in women by Morise AP et al. 
 For the validation group, score ranges are shown with the prevalence of CAD: <20 = 0/5 
or 0%, 20-29 = 3/26 or 11%, 30-39 = 20/56 or 36%, 40-49 = 33/81 or 41%, 50-59 = 
24/49 or 49%, 60-69 = 22/32 or 69%, and >70 = 7/7 or 100%. 
In 1998 Alexander KP et al determined the ability of a treadmill score to provide accurate 
diagnostic and prognostic risk estimates in women. They estimated the diagnostic and 
prognostic value of the DTS in 976 women and 2,249 men who underwent both treadmill 
testing and cardiac catheterization in a single institution from 1984 to 1994.Results. 
Women and men differed significantly in DTS (1.6 vs. −0.3, p < 0.0001), disease 
prevalence (32% vs. 72% significant coronary artery disease [CAD], p < 0.001), and 2-
year mortality (1.9% vs. 4.9%, p < 0.0001). Although overall women had better survival, 
the DTS performed equally well in stratifying both genders into prognostic categories. 
The DTS actually performed better in women than in men for excluding disease. 
 
 
 
 
 
 
 
 

19 
 
 
 
 
Materials and Methods 
 
Study design 
 
Type of study: Cross sectional study 
As we want to correlate the different treadmills scores and identify which one is better to 
predict coronary artery disease in male and female population, cross sectional study is 
good one. By this study design we can find the different treadmill scores and 
angiographic data within a short time, easily and with less cost. 
 
 
Study Area 
 
University Cardiac Center, Bangabandhu Sheikh Mujib Medical University (BSMMU). 
BSMMU is a renowned institute in Bangladesh with good indoor and outdoor facility. It 
also has good inpatient and outpatient services for local and other patients coming from 
distant places. There is a good mix of male and female patients also which is needed to 
test the study hypothesis. Overall, the patients coming in outdoor facility to get treatment 
represent the Bangladeshi population very well and uniformly. 
 
Period of study: November 2016 to November 2017 (One year). 
Study population:All stable patients visited University Cardiac Center, Bangabandhu 
Sheikh Mujib Medical University (BSMMU) for evaluation of stable chest pain. 
 
Sampling Procedures 
 
Patient presented with stable chest pain, who have undergone ETT according to Bruce 
protocol and admitted for CAG, will be selected as case considering inclusion and 
exclusion criteria. Detailed and thorough clinical assessment will be done and recorded. 
All available previous medical documents will be checked meticulously. Patients with 
previous revascularization, left bundle-branch block, paced rhythms or Wolff-Parkinson-
White syndrome (WPW) on resting electrocardiogram (ECG), or valvular heart disease, 
congenital heart disease will be excluded from the study. To avoid falsely increasing the 
accuracy of the exercise treadmill test, patients with a previous myocardial infarction by 
history or by diagnostic Q wave will be excluded. 

20 
 
 
With history, clinical findings and investigations cases other than stable chest pain will be 
excluded. Informed written consent will be taken from the patient. CAG report will be 
collected from the Cath lab after the procedure. 
 
Inclusion criteria: 
1. 
Male and female patients undergone CAG and ETT within 6 months interval 
for stable angina. 
2. 
Age between 30-69 years (Gibbons et al., 2002). 
 
Exclusion criteria: 
1. 
Previous myocardial infarction by history or ECG 
2. 
Previous revascularization or valvular heart disease 
3. 
Baseline abnormalities that may obscure electrocardiographic changes during 
exercise 
 
Left bundle branch block or Right bundle branch block 
 
Left ventricular hypertrophy with repolarization abnormality 
 
Digitalis therapy 
 
Vantricular paced rhythm 
 
Wolf-Perkinson-White syndrome 
 
ST abnormality associated with supraventricular tachycardia or atrial 
fibrillation 
 
 
 
 
 
 

21 
 
 
Procedures during study 
Exercise Treadmill Testing 
Patients will be undergoing treadmill testing using Bruce treadmill protocol. Before 
treadmill testing, the patients will be given a questionnaire. This questionnaire will 
estimate the patient’s exercise capacity before the test and thus will allow most patients to 
reach maximal exercise capacity (Myers 1994). Visual ST-segment deviation will be 
measured at the J junction and will be corrected for pre-exercise ST-segment depression 
while standing; ST slope will be measured over the following 80 ms and will be classified 
as up sloping, horizontal, or down sloping. Slope will be coded as 1 horizontal, down 
sloping, or upslopingST depression and 0 for normal slope (up sloping<2 mm or ST-
segment depression of <0.5 mm). The ST response will be considered which has the most 
horizontal, downsloping or up sloping ST-segment depression in any lead, except aVR, 
during exercise or recovery. An abnormal response will be defined as ≥ 1 mm of 
horizontal or downsloping or ≥2 mm upsloping ST-segment depression (Griffin 2013). 
The exercise tests will be analyzed, and reported per standard protocol and manual 
calculation. Decision for cardiac catheterization will be consistent with clinical practice. 
Analyses will be performed with the investigators blinded to clinical and angiographic 
results. 
Coronary Angiography 
Coronary artery narrowing will be visually estimated and expressed as percent lumen 
diameter stenosis. Patients with a 70% narrowing in one or more of the following is 
considered to have significant angiographic coronary artery disease: the left anterior 
descending, left circumflex, right coronary arteries or their major branches, or a 50% 
narrowing in the left main coronary artery (Kern 2013). 
Treadmill Scores 
Treadmill scores and their calculation are shown in Appendix A. 
 
 
 
 
 

22 
 
 
 
Data collection:  
Data will be recorded in pre-designed questionnaires by history, clinical examination and 
investigation with the patient of University Cardiac Center, BSMMU. 
Quality assurance strategy: 
A set of questionnaire will be formulated & checked. To make the study credible, reliable 
& dependable data will be collected by principal investigator by using those questions 
over a month of period. Again the questions will be edited accordingly & necessarily after 
discussion with the guide and co-guide of this study. 
Ethical Issues  
At first ethical clearance will be taken from the ethical review committee of Bangabandhu 
Sheikh Mujib Medical University (BSMMU). The study will be carried out according to 
1964 Helsinki Declaration for Medical Research involving Human subjects and amended 
by the 64th World Medical Association General Assembly, October 2013. No drugs or 
placebo will be used for this study. Each participant will enjoy every right to participate 
or refuse participation. They will be free to withdraw their participation at any stage of 
the study. Data taken from the participants will be regarded as confidential. Data will be 
used only for this scientific study. Participants will be informed in detail about the nature 
and purpose of the study, and informed written consent will be taken from each 
participant. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

23 
 
 
 
Sample size calculation 
 
 
Sample size is calculated by using the following equation (One sample comparison of 
proportion): 
 n=
⌈𝑍𝛽√𝑝(1−𝑝)+𝑍𝛼√𝑝1(1−𝑃1)⌉
2
(𝑝−𝑝1)²
 
n = required sample size 
p = Proportion under alternative hypothesis that is proposed to be detected or worst 
possible outcome 
p1= Proportion under null hypothesis or proportion in the population 
𝑍𝛼 = 1.96 (5% level of significance) 
Zβ = 1.28 when power is 0.9 
According to Fearon WF et al (2002) the predictive accuracy of DTS is 71% (0.71).  
If we assume:  p1= 0.71 
                         P = 0.55,   Power = 0.8,  𝛼 = 0.05 
Sample 
size 
 
n 
= 
⌈1.28√. 55(1 −.55) + 1.96√. 71(1 −.71)⌉
2
(.55 −.71)²
 
                                                       = 91 
Correction for non-response: 
Nf= 100/100- Nr 
If Nr= Percentage of expected non-response is 10%  
Nf= 100/100- 10   = 1.11 
Final sample size will be estimated sample size (n) x Nf 
= 91 x 1.11 = 102.  So our required sample size is at least 102. 

24 
 
 
StatisticalMethods 
 
Using angiographic evidence of CAD as the reference, area under the curve (AUC) of 
receive operator characteristic (ROC) plots will be determined for the ST response alone and 
for each treadmill score. The AUC for each treadmill score will be compared with the AUC 
of the ST response alone and the AUCs of the other treadmill scores. A significant 
difference is defined as a z-score >1.96, with z-score = (AUC1 – AUC2) / (SE12 + SE22)-2. 
The predictive accuracies of the DTS, the Simple Treadmill Score and Cleveland Clinic 
Score to stratify patients into high or low likelihood for CAD will be calculated and 
compare. Test of agreement will be calculated using Kappa statistics. Statistically significant 
difference between predictive accuracies is defined as a p value <0.05 using the two-tailed 
Fischer’s exact test. Statistical analysis will be performed with the SPSS. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

25 
 
 
 
Dummy Tables/Graphs 
 
 
 
 
 
 
 
 
Area Under the Curve 
Test 
Result 
Variable(s) 
Area 
Std. 
Errora 
Asymptotic 
Sig.b 
Asymptotic 
95% 
Confidence Interval 
Lower 
Bound 
Upper 
Bound 
CCS 
 
 
 
 
STS 
 
 
 
 
DTS 
 
 
 
 
The test result variable(s): CCS, STS, DTS has at least one tie between the positive 
actual state group and the negative actual state group. Statistics may be biased. 
a. Under the nonparametric assumption 
b. Null hypothesis: true area = 0.5 
 
 
 
 
 
 
 
 
 
 

26 
 
 
 
DTS * CAD 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Symmetric Measures 
 
value Asymp. 
Std. 
Errora 
Approx. 
Tb 
Approx. 
Sig. 
Measure of 
Agreement 
Kappa 
 
 
 
 
N of Valid Cases 
 
 
 
 
a. Not assuming the null hypothesis. 
b. Using the asymptotic standard error assuming the null hypothesis. 
Crosstab 
Count 
 
CAD 
Total 
No 
CAD 
NCAD 
Low likelihood 
 
 
 
High Likelihood 
 
 
 
Total 
 
 
 
 
Chi-Square Tests 
 
Value 
Df 
Asymp. 
Sig. 
(2-sided) 
ExactSig. (2-
sided) 
Exact Sig. (1-
sided) 
Pearson Chi-Square 
 
 
 
 
 
Continuity Correctionb 
 
 
 
 
 
Likelihood Ratio 
 
 
 
 
 
Fisher's Exact Test 
 
 
 
 
 
Linear-by-Linear 
Association 
 
 
 
 
 
N of Valid Cases 
 
 
 
 
 
a. 1 cells (25.0%) have expected count less than 5. The minimum expected count is 2.74. 
b. Computed only for a 2x2 table 

27 
 
 
 
STS * CAD 
 
 
Crosstab 
Count 
CAD 
Total 
No CAD CAD 
Low likelihood 
 
 
 
High 
likelihood 
 
 
 
 
 
 
 
 
 
 
 
Symmetric Measures 
 
Value 
Asymp. Std. 
Errora 
Approx. 
Tb 
Approx. 
Sig. 
Measure of 
Agreement 
Kappa 
 
 
 
 
N of Valid Cases 
 
 
 
a. Not assuming the null hypothesis. 
b. Using the asymptotic standard error assuming the null hypothesis. 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chi-Square Tests 
 
Value 
Df 
Asymp. Sig. 
(2-sided) 
Exact Sig. (2-
sided) 
Exact Sig. (1-
sided) 
Pearson Chi-Square 
 
 
 
 
 
Continuity Correctionb 
 
 
 
 
 
Likelihood Ratio 
 
 
 
 
 
Fisher's Exact Test 
 
 
 
 
 
Linear-by-Linear 
Association 
 
 
 
 
 
N of Valid Cases 
 
 
 
 
 
a. 1 cells (25.0%) have expected count less than 5. The minimum expected count is
3.06. 
b. Computed only for a 2x2 table 

28 
 
 
 
CCS * CAD 
 
 
Crosstab 
Count 
 
CAD 
Total 
No CAD CAD 
CC
S 
Low likelihood 
 
 
 
High 
Likelihood 
 
 
 
Total 
 
 
 
 
 
 
 
 
Symmetric Measures 
 
 
Value 
Asymp. Std. 
Errora 
Approx. 
Tb 
Approx. 
Sig. 
Measure of 
Agreement 
Kappa 
 
 
 
 
N of Valid Cases 
 
 
 
a. Not assuming the null hypothesis. 
b. Using the asymptotic standard error assuming the null hypothesis. 
 
 
 
 
 
 
 
 
 
Chi-Square Tests 
 
Value 
df 
Asymp. Sig. 
(2-sided) 
Exact Sig. (2-
sided) 
Exact Sig. (1-
sided) 
Pearson Chi-Square 
 
 
 
 
 
Continuity Correctionb 
 
 
 
 
 
Likelihood Ratio 
 
 
 
 
 
Fisher's Exact Test 
 
 
 
 
 
Linear-by-Linear 
Association 
 
 
 
 
 
N of Valid Cases 
 
 
 
 
 
a. 1 cells (25.0%) have expected count less than 5. The minimum expected count is 
3.54. 
b. Computed only for a 2x2 table 

29 
 
 
 
Operational Definitions 
 
Stable IHD 
Stable IHD is defined as stable angina if there is no substantial change in symptoms over 
several weeks. It is usually characterized by episodes of reversible myocardial supply-
demand mismatch, related to ischemia or hypoxia, which may be inducible by exercise, 
emotion or other stress and reproducible—but, which may also be occurring 
spontaneously. Stable angina has duration less than 20 mins and relieved by taking rest or 
sublingual nitroglycerine. (Partick et al., 1999) 
Chest pain is defined as “typical angina” if it consists of characteristic (1) substernal 
discomfort, (2) is provoked by stress, and (3) is relieved by rest or nitroglycerin. It is 
considered “atypical” if it involves two or less of the previously mentioned criteria. It is 
labeled as non-cardiac chest pain if only one or none of the above three characters is 
present. (Griffin 2013) 
 
STEMI 
New ST elevation at the J point in at least 2 contiguous leads of ≥2 mm (0.2 mV) in men 
or ≥1.5 mm (0.15 mV) in women in leads V2–V3 and/or of ≥1 mm (0.1 mV) in other 
contiguous chest leads or the limb leads (Thygesen et al., 2012). 
The majority of patients will evolve ECG evidence of Q-wave infarction. New or 
presumably new LBBB has been considered a STEMI equivalent. Most cases of LBBB at 
time of presentation, however, are “not known to be old” because of prior 
electrocardiogram (ECG) is not available for comparison. New or presumably new LBBB 
at presentation occurs infrequently, may interfere with ST-elevation analysis, and should 
not be considered diagnostic of acute myocardial infarction (MI) in isolation .Criteria for 
ECG diagnosis of acute STEMI in the setting of LBBB have been proposed . Baseline 
ECG abnormalities other than LBBB (e.g., paced rhythm, LV hypertrophy, Brugada 
syndrome) may obscure interpretation. In addition, ST depression in ≥2 precordial leads 
(V1–V4) may indicate transmural posterior injury; multilead ST depression with 
coexistent ST elevation in lead aVR has been described in patients with left main or 
proximal left anterior descending artery occlusion .  Rarely, hyperacute T-wave changes 

30 
 
may be observed in the very early phase of STEMI, before the development of ST 
elevation (Patrick et al., 2013). 
Acute MI 
The classic world health organization (WHO) criteria for an acute MI require that two of 
the following three elements be present (Thygesen et al., 2012). 
i. A history suggestive of coronary ischemia for a prolonged period of time (> 
30 minutes) 
ii. Evolutionary changes on serial ECGs suggestive of MI and 
iii. A rise and fall in serum cardiac markers consistent with myonecrosis 
 
 
 
UNSTABLE ANGINA/NSTEMI 
Unstable angina (UA) and non–ST-segment elevation myocardial infarction (NSTEMI) 
remain leading causes of morbidity and mortality in the United States. These conditions 
are part of a continuum of acute coronary syndromes (ACSs) that range from UA and 
NSTEMI to ST-segment elevation myocardial infarction (STEMI). The clinical 
presentation of non–ST-elevation acute coronary syndrome (NSTE-ACS) can be variable, 
ranging from progressive exertional angina to postinfarction angina. 
Braunwald classification of unstable angina (Griffin 2013) 
Class              Clinical Characteristics 
I 
Exertional 
angina 
New onset, severe, or accelerated, Angina of < 2 moduration,More frequent 
angina,Angina precipitated by less exertion, No rest angina in the last 2 mo 
II 
Rest 
angina, 
subacute 
Rest angina within the last month but none within 48 h of presentation 
III 
Rest 
angina, 
acute 
Rest angina within 48 h of presentation 

31 
 
                       Clinical Circumstances 
A 
Secondary 
unstable 
angina 
Caused by a noncardiac condition, such as anemia, infection, thyrotoxicosis, or 
hypoxemia 
B 
Primary unstable angina 
C 
Postinfarction 
unstable 
angina 
Within 2 wk of documented myocardial infarction 
 
Because NSTEMI is distinguished from UA by the presence of elevated serum levels of 
cardiac biomarkers, serial measurements in patients presenting with ACS should be 
performed. With improvements in the diagnosis and risk stratification of patients with UA 
and NSTEMI, therapeutic approaches to NSTE-ACS have continued to evolve (Griffin 
2013). 
DIABETES MELLITUS(ADA Guideline, Jan 2016) 
Diabetes is a group of metabolic diseases characterized by hyperglycemia resulting from 
defects in insulin secretion, insulin action, or both. Diabetes mellitus is defined by 
HbA1C ≥ 6.5% or fasting plasma glucose of 7.0 mmol/L or above, or post- prandial 
plasma glucose of 11.1 mmol/L or above with symptoms of hyperglycemia. An abnormal 
oral glucose tolerance test done recently or previously diagnosed as DM by a physician 
with or without on antidiabetic medication are also considered as diabetic patient.  
 
SMOKING(Cannon, et  al., 2001 ) 
History of confirmed cigarette smoking in the past or in recent days is classified as 
following categories- 
1. Current: Smoking cigarettes within 1 month of this admission. 
2. Recent: Stopped smoking cigarettes between 1 month and 1 year before this admission. 
3. Former: Stopped smoking cigarettes more than 1 year before this admission. 
4. Never: Never smoked cigarettes. 
 
 
 

32 
 
HYPERTENSION (Whelton et al., 2017) 
Sustained elevation of systolic and/or diastolic blood pressure which is measured over 
few weeks or history of taking medication for elevated blood pressure has considered as 
hypertension. The following categories are considered while labeling hypertension. 
Categories of blood pressure 
Sytolic Blood Pressure 
(mmHg) 
 
Diastolic Blood 
Pressure 
(mmHg) 
Normal 
<120 
and 
<80 
Elevated BP 
120-129 
and 
<80 
Stage 1 Hypertension 
130-139 
 
80-89 
Stage 2 Hypertension 
≥ 140 
 
≥ 90 
 
 
DYSLIPIDEMIA(Adult Treatment Panel III, 2001)  
Patient has history of abnormal blood lipid profile or on treatment due to high blood lipid 
by a physician or current blood reports showing any of the following -  
LDL Cholesterol……………≥ 100 mg/dl 
Total Cholesterol…………..≥200 mg/dl  
HDL Cholesterol………… ≤40 mg ⁄ dl. 
Serum Triglycerides………..≥150 mg/dl  
 
OBESITY AND OVERWEIGHT 
Overweight and obesity are defined as abnormal or excessive fat accumulation that may 
impair health. 
Body mass index (BMI) is a simple index of weight-for-height that is commonly used to 
classify overweight and obesity in adults. It is defined as a person's weight in kilograms 
divided by the square of his height in meters (kg/m2). 
According to the WHO definition for Asian population (Who expert consultation, 2004): 

33 
 
 
BMI greater than or equal to 23 is overweight 
 
BMI greater than or equal to 25 is obesity. 
FAMILY HISTORY OF CAD 
Any first degree relatives (parents, siblings or offspring) who have had any of the 
following at age less than 55 years in case of male and less than 65 years in case of 
female-  
1. Typical Angina or  
2. Myocardial Infarction  
3. Sudden cardiac death without obvious cause. 
 
CORONARY ARTERY DISEASE 
Patients with a 70% narrowing in one or more of the following is considered to have 
significant angiographic coronary artery disease: the left anterior descending, left 
circumflex, right coronary arteries or their major branches, or a 50% narrowing in the left 
main coronary artery. Ischemic heart disease and coronary artery disease terms are used 
interchangeably (Kern M.J. 2013). 
The extent and severity of CAD is defined as 1-vessel, 2-vessel, 3-vessel, or left main 
disease, with a significant stenosis ≥70% diameter reduction. (Neglia, et al., 2015) 
CORONARY ANGIOGRAM/ CARDIAC CATHETERIZATION 
Left heart catheterization or coronary arteriography remains the clinical gold standard for 
determining the presence of significant coronary artery disease (CAD). 
Cardiac catheterization is the insertion and passage of small plastictubes (catheters) into 
the heart to obtain x-raypictures (angiography) of coronary arteries. The cardiac 
catheterization laboratory performs angiography to obtain images to diagnose coronary 
artery disease as well as other disease condition (Kern M.J. 2013). 
 
 
 
 

34 
 
Stable IHD 
Anginal symptoms are defined as stable if there is no substantial change in symptoms 
over several weeks. Symptoms of stable angina can fluctuate from time to time, 
depending on myocardial oxygen consumption, emotional stress, or change in ambient 
temperature. In general, the clinical definition of stable angina pectoris closely correlates 
with the stability or quiescence of an atherosclerotic plaque and decreased clinical risk. 
Chest pain is defined as “typical angina” if it consists of characteristic (1) substernal 
discomfort, (2) is provoked by stress, and (3) is relieved by rest or nitroglycerin. It is 
considered “atypical” if it involves two or less of the previously mentioned criteria. 
(Griffin 2013) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

35 
 
References 
Adult Treatment Panel III, 2001.  Executive Summary of the Third Report of The 
National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation 
and Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). Journal 
of American Medical Association, vol.285,no.19, pp.2486-97 
Alexander, K.P., Shaw, L.J., DeLong, E.R.,Mark, D.B., Peterson, E.D. 1998, ‘Value of 
exercise treadmill testing in women’, J Am CollCardiol , Vol. 32, No. 6, pp.1657-1664 
Berman, J.L., Wynne, J., Cohn, P.F. 1978,‘A multivariate approach to interpreting 
treadmill exercise tests in coronary artery disease’,Circulation, Vol. 58, pp. 505–512 
 
Canon, C.P., Battler, A., Brindis, R.G., Cox, J. L., Ellis, S. G., Every, N.R., Flaherty, J.T., 
Harrington, R.A., Krumholz, H.M., Simoons, M.L.,2001.ACC CLINICAL DATA 
STANDARDS, American College of Cardiology Key Data Elements and Definitions for 
Measuring the Clinical Management and Outcomes of Patients with Acute Coronary 
Syndromes.A Report of theAmerican College of Cardiology Task Force on Clinical Data 
Standards (Acute Coronary Syndromes Writing Committee).J Am CollCardiol, 
vol.38.no.7, pp. 2114-30. 
 
 
Detrano, R., Gianrossi, R., Mulvihill, D., Lechman, K., Dubach, P.,Colombo, A., et al. 
1989, ‘Exercise-induced ST segment depression in the diagnosis of multivessel coronary 
disease: a meta analysis’, J Am CollCardiol, Vol. 14, pp. 1501–8 
 
Detrano, R., Bobbio, M., Olson, H., Shandling, A., Ellestad, M.H., Alegria, E., 
Steinbrunn, W., Pfisterer, M., Sanna, G., Ferarri, G., Guppy, K.H., Schmid, J., Deckers, 
J., Le, H.M., Brezden, O., Colombo, A. 1992, ‘Computer probability estimates of 
angiographic coronary artery disease: Transportability and comparison with cardiologists’ 
estimates’, Comp Biomed Res Vol. 25, pp. 468–485 
 
Do, D., West, J.A., Morise, A., Atwood, E., Froelicher, V. 1997, ‘A consensus approach 
to diagnosing coronary artery disease based on clinical and exercise test data’, Chest, Vol. 
111, pp. 1742–1749 
 
Fearon, W.F., Gauri, A.J., Myers, J., Raxwal, V.K., Atwood, J.E., Froelicher, V.F. 
2002,‘A comparison of treadmill scores to diagnose coronary artery disease’, ClinCardiol, 
Vol. 25, No. 3, pp.117-22 
 
Gianrossi, R., Detrano, R., Mulvihill, D., Lehmann, K., Dubach, P., Colombo, A., et al. 
1989, ‘Exercise-induced ST depression in the diagnosis of coronary artery disease: a 
metaanalysis’, Circulation, Vol. 80, pp. 87-98 
 
Gibbons, R.J., Balady, G.J., Bricker, J.T., et al. 2002, ‘ACC/AHA  2002 guideline update 
for exercise testing: Summary article. A report of the American College of Cardiology 
/American Heart Association Task Force on Practice Guidelines’, J amCollCardiol, Vol. 
40, pp.1531 
 

36 
 
Griffin, B.P. (ed.) 2013, Manual of Cardiovascular Medicine, 4thedn, Lippincott Williams 
& Wilkins, New Delhi, India, pp. 02-95 
 
Günaydın, Z.Y., Bektaş, O., Gürel, Y.E., Karagöz, A., Kaya, A., Kırış, T., Zeren, 
G., Yazıcı, S. 2015 Jul 23, ‘Value of Duke treadmill score in predicting presence and 
severity of coronary artery disease', Kardiol Pol, Vol. 74, No. 2,  pp.127-34 
Hollenberg, M., Zoltick, J.M., Go, M., Yaney, S.F., Daniels, W., Davis, R.C., Bedynek, 
J.L. 1985, ‘Comparison of a quantitative treadmill exercise score with standard 
electrocardiographic criteria in screening asymptomatic young men for coronary artery 
disease’,N Engl J Med, Vol. 313, pp. 600–606 
 
Islam, A.K.M.M., Majumder, A.A.S. 2013 Jul, ‘Coronary artery disease in Bangladesh: A 
review’, Indian Heart J, Vol. 65, No. 4, pp. 424-435 
 
 
 
Jamal, A.,  Homa, D.M., O’Connor, E., et al. 2015, ‘Current Cigarette Smoking Among 
Adults — United States, 2005–2014’,  MMWR Morb Mortal Wkly Rep 2015, Vol. 64, 
pp. 1221-1226 
 
Kronander, H., Fischer‐Colbrie, W., Nowak, J., Brodin, L.A., Elmqvist, H. 2010, 
‘Diagnostic performance and partition values of exercise electrocardiographic variables in 
the detection of coronary artery disease‐‐improved accuracy by using ST/HR hysteresis’, 
ClinPhysiolFunct Imaging, Vol. 30, No. 2, pp. 98‐106  
 
Kern, M.J. 2013, The Cardiac Catheterization Handbook, 5thedn, Elsevier, India, pp. 159-
161 
 
Lauer, M.S., Pothier, C.E., Magid, D.J., et al 2007, ‘An externally validated model for 
predicting long-term survival after exercise treadmill testing in patients with suspected 
coronary artery disease and a normal electrocardiogram’, Ann Intern Med, Vol. 147, No. 
821,pp. 821-8 
 
Mark, D.B., Hlatky, M.A., Harrell, F.E., Lee, K.L., Califf, R.M., Pryor, D.B. 1987, 
‘Exercise treadmill score for predicting prognosis in coronary artery disease’, Ann Intern 
Med, Vol. 106, No. 6, pp. 793-800 
 
Morise, A.P., Detrano, R., Bobbio, M., Diamond, G.A. 1992, ‘Development and 
validation of a logistic regression-derived algorithm for estimating the incremental 
probability of coronary artery disease before and after exercise testing’,J Am CollCardiol, 
Vol. 20, pp.1187–1196 
 

37 
 
Myers, J., Do, D., Herbert, W., Ribisl, P., Froelicher, VF. 1994, ‘A nomogram to predict 
exercise capacity from a specific activity questionnaire and clinical data’, Am J Cardiol, 
Vol. 73, pp. 591–596 
 
Morise, A.P., Lauer, M.S., Froelicher, V.F. 2002 Nov. , ‘Development and validation of 
a simple exercise test score for use in women with symptoms of suspected coronary artery 
disease’, Am Heart J, Vol. 144, No. 5, pp. 818- 
 
Mancia, G., et al. 2007, ‘2007 Guidelines for the management of arterial hypertension. 
The Task Force for the Management of Arterial Hypertension of the European Society of 
Hypertension (ESH) and of the European Society of Cardiology (ESC)’, Journal of 
Hypertension, Vol. 25, pp.1105–1187 
 
 
Myerburg, R.J., Castellanos, A. 2011, ‘Cardiac arrest and sudden cardiac death – Chapter 
41, In: Libby, P., Bonow, R.O., Mann, D.L., et al. eds, Braunwald’s Heart Disease: A 
Textbook of Cardiovascular Medicine, 9th ed, Elsevier Saunders, Philadelphia, PA, pp 
821-836 
 
National Heart, Lung and Blood Institute 2016, ‘What is arrhythmia?’, available from: 
http://www.nhlbi.nih.gov [Accessed 9thNovember 2016]  
 
Neglia, D., Rovai, D., Caselli, C., Pietella, M., Terasinska, A., Bruix, S.A., et al. 2015, 
‘Detection of Significant Coronary Artery Disease by Noninvasive Anatomical and 
Functional Imaging. Circulation’, Cardiovascular Imaging, Vol. 8: e002179 
 
Patrick, T.O., et al. 2013, ‘2013 ACCF/AHA Guideline for the Management of ST-
Elevation Myocardial Infarction. A Report of the American College of Cardiology 
Foundation/American Heart Association Task Force on Practice Guidelines’,  J Am 
CollCardiol , Vol. 61, No. 4, e78-e140 
 
Raxwal, V., Shetler, K., Morise, A., Do, D., Myers, J., Atwood, J.E., Froelicher, V.F. 
2002 Jun, ‘Simple treadmill score to diagnose coronary disease’, Chest, Vol. 119, No. 6, 
pp.1933-40 

38 
 
Shaw, L.J., Peterson, E.D., Shaw, L.K., Kesler, K.L., DeLong, E.R., Harrell, F.E., 
Muhlbaier, L.H., Mark, D.B. 1998,‘Use of a Prognostic Treadmill Score in Identifying 
Diagnostic Coronary Disease Subgroups’, Circulation, Vol. 98, pp. 1622-1630 
Takase, B., Masaki, N., Hattori, H., Ishihara, M., Kurita, A. 2009, ‘Usefulness of 
automatic QT dispersion measurement for detecting exercise‐ induced myocardial 
ischemia. AnadoluKardiyolDerg, Vol. 9, No. 3, pp. 189‐195 (PMID: 19520652) 
Taimur, S.D.M., Khan, S.R., Islam, F. 2014, ‘Angiographic Evaluation of ETT 
(Treadmill) Positive Patients in a Tertiary Care Hospital of Bangladesh’, International 
Journal of Medical, Health, Biomedical, Bioengineering and Pharmaceutical Engineering, 
Vol. 8, No. 12 
Thygesen, K., Alpert, J.S., Jaffe, A.S., et al 2012, ‘Third universal definition of 
myocardial infarction’, Circulation, Vol. 126, pp. 2020-2035 
 
Yusuf, S., Zucker, D., Peduzzi, P., Fisher, L.D., Takaro, T., Kennedy, J.W., Davis, K., 
Killip, T., Passamoni, E., Norris, R., Morris, C., Virendra, M., Varnauskas, E., Chalmers, 
T.C. 1994, ‘Effect of coronary artery bypass graft surgery on survival: Overview of 10- 
year results from randomized trials by the Coronary Artery Bypass Graft Surgery Trialists 
Collaboration’,  Lancet, Vol. 344, pp.563–570 
Zhang, S.L., Jiang, Y., Xu, H.M., Qju, H.X. 2007, ‘A comparative study on treadmill 
exercise test and coronary angiography in the diagnosis of coronary artery disease: report 
of 267 cases’, Journal of the Fourth Military Medical University, Vol. 28, No. 21 
WHO expert consulation 2004,‘Appropriate body-mass index for Asian populations and 
its implications for policy and intervention strategies’,Lancet, Vol. 363, No. 9403, 
pp.157-63 
 
 
Whelton, P.K., Carey, R.M., Aronow, W.S., et al., 
2017.ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the 
Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults.A Report 
of the American College of Cardiology/American Heart Association Task Force on Clinical 
Practice Guidelines. Hypertension. 2017 Nov 

39 
 
 
Appendix A 
Treadmill Scores and their calculation 
The DTS will be calculated as DTS = exercise time - (5 x ST deviation) - (4 x exercise 
angina), with 0 = none, 1 = non-limiting, and 2 = exercise-limiting angina. The METs will be 
calculated by modified Bruce protocol and be inputted into the DTS equation (Fletcher et al., 
1995). Based on the study by Shaw et al. (1998), a DTS < + 5 is considered abnormal. High 
risk  when DTS is < -10 and low risk when DTS is > +5. 
 
The simple Treadmill Score for men will calculated as follows:  
      (6 x maximal heart rate code) + (5 x ST-segment depression code) + (4 x age code) + 
angina pectoris code + hypercholesterolemia code + diabetes code + treadmill angina 
index code. 
 
The simplified score had a range from 6 to 95, with < 40 designated as low probability, 
between 40 and 60 was intermediate probability, and > 60 was high probability for CAD. 
 
For male patient 
Variable 
Choose Response 
Sum 
Maximal HR 
<100 bpm = 30 
 
100-129 bpm = 24 
130-159 bpm = 18 
160-189 bpm = 12 
190-220 bpm = 6 
Exercise ST depression 
1 – 2 mm = 15 
 
>2 mm = 25 
Age 
>55 yr = 20 
 
40-55 yr = 12 
Angina history 
Definite/typical = 5 
 
Probable/atypical = 3 

40 
 
Non-cardiac pain = 1 
Hypercholesterolemia 
Yes = 5 
 
Diabetes 
Yes = 5 
 
Exercise 
test: 
induced 
angina 
 Occurred = 3 
 
Reason for stopping = 5 
 
Total score: 
 
 
For Female patients 
Variable 
Choose Response 
Sum 
Maximal HR 
<100 bpm = 20 
 
100-129 bpm = 16 
130-159 bpm = 12 
160-189 bpm = 8 
190-220 bpm = 4 
Exercise ST depression 
1 – 2 mm = 6 
 
>2 mm =10 
Age 
>65yr = 25 
 
50-65 yr = 15 
Angina History 
Definite/typical = 10 
 
Probable/atypical = 6 
Non-cardiac pain = 2 
Smoking 
Yes = 10 
 
Diabetes 
Yes = 10 
 
Exercise test: Induced angina 
 Occurred = 9 
 
Reason for stopping = 15 
Estrogen status 
+ve = -5,   -Ve = 5 
 
 
Total = 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

41 
 
 
 
 
 
Cleveland Clinic Score:(Lauer et al., 2007) 
 
Arbitrarily, we assume CCS will predict significant CAD with high 
probability if the value is > 140 and low probability it is <100. 
 
 
Fig: Cleveland Clinic Score Nomogram. 
 
 
 

42 
 
 
 
Appendix B 
 
Study design flow chart: 
 
 
Patient with Stable chest pain who underwent ETT and admitted for CAG 
 
 
 
 
Patient selected according to Inclusion and exclusion criteria 
 
 
 
 
DTS, Simple Treadmill Score, Cleveland Clinic score calculated 
 
 
 
 
Report collection after CAG 
 
 
 
 
 
Data for analysis 
 
 
 
 

43 
 
 
 
Appendix C 
 
Questionnaire/ Data Collection Form 
Title: A comparative study of different treadmill scores to diagnose 
Coronary Artery Disease in among patients attending Bangabandhu 
Sheikh Mujib Medical University. 
SL No…………………                                            Date: ………………… 
Name: ………………………………………….. 
Address: ………………………………………………… 
Hospital Reg. No. …………...... 
Date of ETT: …………………… Date of CAG: ………………. CD No……………… 
Demographic and anthropometric variables: 
1. 
Age:                 ……………Yrs 
2. 
Gender:           1= Male   2= Female      
3. 
Weight:            …………… Kg        
4. 
Height:             …………… cms 
5. 
Marital status: 0= No     1= yes                                                                                                                
Baseline variables: 
6. 
Anginal pain:         0= Non cardiac  1=Typical  2= Atypical                         
7. 
Past Smoker:         0= No                                       1= Yes                                
8. 
Current smoker:   0= No                                       1= Yes             
9. 
Hypertension:        0= No                                      1= Yes                          
10. 
NIDDM:                 0= No                                      1= Yes      
11. 
IDDM:                    0= No                                      1= Yes         
12. 
Oestrogen status:   0= Negative                           1= Positive                   
13. 
Family history of CAD:     0= No                         1= Yes               

44 
 
 
 
14. 
Sudden death of 1st degree relatives:  0= No   1= Yes       
 
 
Biochemical Investigations: 
15. 
Lipid profile: TC….. mg/dl; LDL…… mg/dl; HDL….. mg/dl; TG…... mg/dl  
16. 
RBS:                             ….………mg/dl                                  
17. 
Serum creatinine: ……………..mg/dl                                                      
Exercise test variables: 
18. 
Duration of exercise:                       ………..min              
19. 
METs                                                   ……….                        
20. 
Maximum Heart Rate:                     ………bpm 
21. 
Peak Systolic BP:                              ………mmHg                          
22. 
Maximum ST segment depression: ………mm                     
23. 
Exercise induced angina:  0= No angina  1= Non-test limiting 
 
       2= Test limiting angina 
24. 
Abnormal heart rate recovery: 0= No     1= Yes             
 
 
25. 
Frequent VE during recovery:  0= No     1= Yes 
 
 
 
 
 
26. 
Duke Treadmill Score:  ……….   0= Low risk    
     1= High risk         
 
 
27. 
Simple Treadmill Score: ……….. 0=Low probability   
 
 
 
 
 
     1=High probability  
 
28. 
Cleveland Clinic Score: ………..  0=Low probability  
      1= High probability                             
 
Coronary angiogram: 
29. 
Extent of disease: 0= Normal,  1=SVD, 2= DVD, 3= TVD, 4=LM 
 
 
 
 
 
 

45 
 
 
Appendix D 
Informed written consent 
The objective of this consent from is to inform you all necessary information to help you 
decide whether you want to participate in this study or not.  
Objectives & Procedures: 
This study will be conducted on the patients visiting Bangabandhu Sheikh Mujib Medical 
University (BSMMU) with the complaints of chest pain or shortness of breath or 
palpitation. At first ECG, ETTfindings of these patients will be recorded. Subsequently 
who are eligible for coronary angiogram (CAG), will be undergone this procedure. 
Thought this study high risk patients can be identified only by ETT and by providing 
timely medical treatment incidence of mortality and morbidity can be reduced. Provided 
you are eager to participate in this study, the physician involved in this research will ask 
you few questions regarding your health and life style. Numerous patients may get up to 
date treatment with the help of this study outcome. 
Risks: 
Participants of this study will get all necessary treatment according to current standard 
medical guideline. ECG, Echo, ETT are non-invasive tests having no risk of death or 
physical injury. CAG is an invasive test and is a common procedure here in the 
department of cardiology, BSMMU to diagnose and confirm Coronary Artery Disease. 
Chance of major complication during and after the procedure is in minimal. 
Benefits: 
If you participate in this study you will be benefited in the long run. By this study we will 
be able to detect high risk patients with the help of ETT alone, which is easy, less costly 
and has negligible risk. And overall mortality related to cardiac disease can be restricted. 
Alternatives: 
You can independently decide to participate or not to participate. And after participation 
you can withdraw yourself from this study anytime. 
 

46 
 
 
 
Cost:  
You do not need to spend for you participation in this research activities. At the same 
time no allowance will be assigned to you for your participation. 
Privacy: 
During and after the research activity your privacy will be maintained confidentially. An 
I.D. will be assigned for future follow up and references. All your documents will be 
labeled with your name and address, and will be under lock and key. 
Voluntary participation: 
Your participation in this study is all voluntary. You can disagree to participate or can 
withdraw yourself from this study anytime. Despite that your current treatment will not be 
hampered and your legal rights will be abrogated while you are a participant. 
Queries:  
If you have any query, please do ask us. We will be happy to answer your questions. Also 
if any question arises in future while you are in the study, please communicate with the 
physician. 
Consent Agreement: 
I theundersigned satisfied after talking with the investigator of this study. I understand 
this participation is voluntary and I can with draw anytime without any bindings. I have 
read the aforementioned conditions and I agree to participate in this study. 
 
 
 
Interviewer’s Signature 
 
 
Participant’s Signature 
First Witness: 
Date: 
 
 
 
 
Date:  
 
 
Second Witness: 
 

47 
 
 
 
Appendix E 
Abbreviations 
ACC…………………………………..American College of Cardiology 
AHA………………………………….American Heart Association 
BMI…………………………………..Body Mass Index 
BP…………………………………….Blood Pressure 
BSMMU………………………….. ...Bangabandhu Sheikh Mujib Medical University   
CAD…………………………………Coronary Artery Disease 
DVD ………………………………....Double Vessel Disease 
DTS…………………………………Duke Treadmill Test 
CAG………………………………....Coronary angiogram 
ETT………………………………….Exercise Tolerance Test/ Exercise Treadmill Test 
ECG………………………………....Electrocardiogram 
HDL………………………………….High Density Lipoprotein  
HR……………………………….. …Heart Rate 
IDDM………………………………...Insulin dependent diabetes mellitus 
IHD…………………………………..Ischemic Heart Disease 
HTN………………………………….Hypertension 
LBBB………………………………...Left Bundle Branch Block 
LVH……………………………….…Left Ventricular Hypertrophy 
LDL……………………………….…Low density lipoprotein 
MET………………………………….Metabolic Equivalent 
MI……………………………………Myocardial Infarction 
NIDDM………………………………Non insulin dependent diabetes mellitus 
SD……………………………….......Standard Deviation 
SPSS…………………………..........Statistical Program for Social Science 
SVD……………………………….…Single Vessel Disease 
TVD………………………………….Triple Vessel Disease 
VE……………………………………Ventricular Ectopic 
WPW………………………………. Wolf-Perkison-White syndrome