We appreciate the interest in our article, comparing stress echocardiography and multidetector computed tomography in a chest pain unit. Although they were not our objectives, we agree that clinical indexes1 and high-sensitivity troponin determination2 are useful to reduce the need for techniques to detect ischemia and coronary disease.
Our article reports one of the indexes mentioned in your letter, the TIMI risk score (68% of patients in TIMI I and 32% in TIMI II). We calculated the percentage of patients with a CPU-65 index of 0 to 1 and found it to be 45%, with no significant differences between the 2 strategies. Irrespective of this finding, the high prevalence of the definite diagnosis of acute coronary syndrome (26%) indicates that the techniques to detect ischemia and coronary disease were not overused.
One of the limitations mentioned was the use of conventional troponin determination. The absence of high-sensitivity troponin determination at inclusion may have contributed to a higher pretest probability of acute coronary syndrome and a greater yield of the diagnostic imaging techniques, which might not apply to a more current population.3
In any event, the use of clinical indexes and high-sensitivity troponin does not completely eliminate the need for functional or anatomical tests to detect coronary disease in a part of the population referred to a chest pain unit, and in our opinion, none of the factors mentioned affects the validity of the results of our study.