scholarly journals Clinical pre-test probability for obstructive coronary artery disease: insights from the European DISCHARGE pilot study

2020 ◽  
Author(s):  
Sarah Feger ◽  
Paolo Ibes ◽  
Adriane E. Napp ◽  
Alexander Lembcke ◽  
Michael Laule ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Chest Pain ◽  
Coronary Artery ◽  
Pilot Study ◽  
Prediction Models ◽  
Obstructive Coronary Artery Disease ◽  
Disease Prevalence ◽  
Artery Disease ◽  
Stable Chest Pain ◽  
Test Probability

Abstract Objectives To test the accuracy of clinical pre-test probability (PTP) for prediction of obstructive coronary artery disease (CAD) in a pan-European setting. Methods Patients with suspected CAD and stable chest pain who were clinically referred for invasive coronary angiography (ICA) or computed tomography (CT) were included by clinical sites participating in the pilot study of the European multi-centre DISCHARGE trial. PTP of CAD was determined using the Diamond-Forrester (D+F) prediction model initially introduced in 1979 and the updated D+F model from 2011. Obstructive coronary artery disease (CAD) was defined by one at least 50% diameter coronary stenosis by both CT and ICA. Results In total, 1440 patients (654 female, 786 male) were included at 25 clinical sites from May 2014 until July 2017. Of these patients, 725 underwent CT, while 715 underwent ICA. Both prediction models overestimated the prevalence of obstructive CAD (31.7%, 456 of 1440 patients, PTP: initial D+F 58.9% (28.1–90.6%), updated D+F 47.3% (34.2–59.9%), both p < 0.001), but overestimation of disease prevalence was higher for the initial D+F (p < 0.001). The discriminative ability was higher for the updated D+F 2011 (AUC of 0.73 95% confidence interval [CI] 0.70–0.76 versus AUC of 0.70 CI 0.67–0.73 for the initial D+F; p < 0.001; odds ratio (or) 1.55 CI 1.29–1.86, net reclassification index 0.11 CI 0.05–0.16, p < 0.001). Conclusions Clinical PTP calculation using the initial and updated D+F prediction models relevantly overestimates the actual prevalence of obstructive CAD in patients with stable chest pain clinically referred for ICA and CT suggesting that further refinements to improve clinical decision-making are needed. Trial registration https://www.clinicaltrials.gov/ct2/show/NCT02400229 Key Points • Clinical pre-test probability calculation using the initial and updated D+F model overestimates the prevalence of obstructive CAD identified by ICA and CT. • Overestimation of disease prevalence is higher for the initial D+F compared with the updated D+F. • Diagnostic accuracy of PTP assessment varies strongly between different clinical sites throughout Europe.

scholarly journals Pre-test probability of obstructive coronary artery disease in the new guidelines: too much, too little or just enough?

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
P Lopes ◽  
F Albuquerque ◽  
P Freitas ◽  
B Rocha ◽  
G Cunha ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Chest Pain ◽  
Obstructive Coronary Artery Disease ◽  
P Value ◽  
Coronary Syndrome ◽  
Luminal Stenosis ◽  
Artery Disease ◽  
Stable Chest Pain ◽  
New Guidelines ◽  
Test Probability

Abstract Background Previous 2013 ESC guidelines recommended the use of the Modified Diamond-Forrester method to assess the pre-test probability (PTP) of obstructive coronary artery disease (CAD). The 2019 ESC Chronic Coronary Syndrome guidelines updated this recommendation with a major downgrade in PTP. The aim of this study was to compare the performance of these two methods in patients with stable chest pain undergoing coronary computed tomography angiography (CCTA) for suspected CAD. Methods We performed a retrospective analysis on prospectively collected data from a cohort of consecutive patients undergoing CCTA for suspected CAD from October 2016 to 2019. Key exclusion criteria were age &lt;30 years-old, known CAD, suspected acute coronary syndrome or symptoms other than chest pain. Obstructive CAD was defined as any luminal stenosis ≥50% on CCTA. Whenever invasive coronary angiography (ICA) was subsequently performed, patients were reclassified if luminal stenosis was &lt;50%. The two PTP prediction models were assessed for calibration and discrimination. Results A total of 320 patients (median age 63 years [IQR 53–70], 59% women) were included. Chest pain characteristics were: 48% atypical angina, 38% non-anginal chest pain, 14% typical angina. The observed prevalence of obstructive CAD was 16.3% (n=52). Patients with obstructive CAD were more often male, were significantly older and had a higher prevalence of typical angina and cardiovascular risk factors (except for family history of CAD). On average, individual PTP was 22.1% lower in the new guidelines. The 2013 prediction model significantly overestimated the likelihood of obstructive CAD (mean PTP 37.3% vs 16.3%; relative overestimation of 130%, p-value for miscalibration 0.005). The updated 2019 method showed good calibration for predicting the likelihood of obstructive CAD (mean PTP 15.2% vs 16.3%; relative underestimation of 6.5%, p-value for miscalibration 0.712). The two approaches showed similar discriminative power, with a C-statistics of 0.730 and 0.735 for the 2013 and 2019 methods, respectively (p-value for comparison 0.933). Stratification by gender produced similar results. Conclusions In patients with stable chest pain undergoing CCTA, the updated 2019 prediction model allows for a more precise estimation of pre-test probabilities of obstructive CAD than the previous model. Adoption of this new score may improve disease prediction and change the downstream diagnostic pathway in a significant proportion of cases. Graph 1 Funding Acknowledgement Type of funding source: None

Clinical and coronary haemodynamic determinants of recurrent chest pain in patients without obstructive coronary artery disease — A pilot study

2018 ◽  
Vol 267 ◽  
pp. 16-21 ◽  
Author(s):  
Abdul R. Sheikh ◽  
Christopher J. Zeitz ◽  
Sharmalar Rajendran ◽  
David P. Di Fiore ◽  
Rosanna Tavella ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Chest Pain ◽  
Coronary Artery ◽  
Pilot Study ◽  
Obstructive Coronary Artery Disease ◽  
Artery Disease

scholarly journals Validation of European Society of Cardiology pre-test probabilities for obstructive coronary artery disease in suspected stable angina

2020 ◽  
Vol 6 (4) ◽  
pp. 293-300 ◽  
Author(s):  
Rong Bing ◽  
Trisha Singh ◽  
Marc R Dweck ◽  
Nicholas L Mills ◽  
Michelle C Williams ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
European Society ◽  
Controlled Trial ◽  
Obstructive Coronary Artery Disease ◽  
Disease Prevalence ◽  
Clinical Events ◽  
Artery Disease ◽  
European Society Of Cardiology ◽  
Test Probability

Abstract Aims  To assess contemporary pre-test probability estimates for obstructive coronary artery disease in patients with stable chest pain. Methods and results  In this substudy of a multicentre randomized controlled trial, we compared 2019 European Society of Cardiology (ESC)-endorsed pre-test probabilities with observed prevalence of obstructive coronary artery disease on computed tomography coronary angiography (CTCA). We assessed associations between pre-test probability, 5-year coronary heart disease death or non-fatal myocardial infarction and study intervention (standard care vs. CTCA). The study population consisted of 3755 patients (30–75 years, 46% women) with a median pre-test probability of 11% of whom 1622 (43%) had a pre-test probability of &gt;15%. In those who underwent CTCA (n = 1613), the prevalence of obstructive disease was 22%. When divided into deciles of pre-test probability, the observed disease prevalence was similar but higher than the corresponding median pre-test probability [median difference 2.3 (1.3–5.6)%]. There were more clinical events in patients with a pre-test probability &gt;15% compared to those at 5–15% and &lt;5% (4.1%, 1.5%, and 1.4%, respectively, P &lt; 0.001). Across the total cohort, fewer clinical events occurred in patients who underwent CTCA, with the greatest difference in those with a pre-test probability &gt;15% (2.8% vs. 5.3%, log rank P = 0.01), although this interaction was not statistically significant on multivariable modelling. Conclusion  The updated 2019 ESC guideline pre-test probability recommendations tended to slightly underestimate disease prevalence in our cohort. Pre-test probability is a powerful predictor of future coronary events and helps select those who may derive the greatest absolute benefit from CTCA.

scholarly journals Prevalence and clinical implications of valvular calcification on coronary computed tomography angiography

2020 ◽  
Author(s):  
Michelle C Williams ◽  
Daniele Massera ◽  
Alastair J Moss ◽  
Rong Bing ◽  
Anda Bularga ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Chest Pain ◽  
Coronary Artery ◽  
Mitral Valve ◽  
Coronary Computed Tomography Angiography ◽  
Obstructive Coronary Artery Disease ◽  
Valve Calcification ◽  
Artery Disease ◽  
Stable Chest Pain ◽  
Mitral Valve Calcification

Abstract Aims Valvular heart disease can be identified by calcification on coronary computed tomography angiography (CCTA) and has been associated with adverse clinical outcomes. We assessed aortic and mitral valve calcification in patients presenting with stable chest pain and their association with cardiovascular risk factors, coronary artery disease, and cardiovascular outcomes. Methods and results In 1769 patients (58 ± 9 years, 56% male) undergoing CCTA for stable chest pain, aortic and mitral valve calcification were quantified using Agatston score. Aortic valve calcification was present in 241 (14%) and mitral calcification in 64 (4%). Independent predictors of aortic valve calcification were age, male sex, hypertension, diabetes mellitus, and cerebrovascular disease, whereas the only predictor of mitral valve calcification was age. Patients with aortic and mitral valve calcification had higher coronary artery calcium scores and more obstructive coronary artery disease. The composite endpoint of cardiovascular mortality, non-fatal myocardial infarction, or non-fatal stroke was higher in those with aortic [hazard ratio (HR) 2.87; 95% confidence interval (CI) 1.60–5.17; P &lt; 0.001] or mitral (HR 3.50; 95% CI 1.47–8.07; P = 0.004) valve calcification, but this was not independent of coronary artery calcification or obstructive coronary artery disease. Conclusion Aortic and mitral valve calcification occurs in one in six patients with stable chest pain undergoing CCTA and is associated with concomitant coronary atherosclerosis. Whilst valvular calcification is associated with a higher risk of cardiovascular events, this was not independent of the burden of coronary artery disease.

ESC guidelines on stable chest pain: a comparison of the previous and current risk scores for the assessment of pre-test probability of coronary artery disease

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
S Fyyaz ◽  
O Olabintan ◽  
S David ◽  
S Plein ◽  
K Alfakih
Keyword(s):  
Coronary Artery Disease ◽  
Chest Pain ◽  
Coronary Artery ◽  
Risk Scores ◽  
Severe Stenosis ◽  
Mild Stenosis ◽  
Esc Guidelines ◽  
Artery Disease ◽  
Stable Chest Pain ◽  
Test Probability

Abstract Introduction The European Society of Cardiology (ESC) guidelines on stable chest pain recommend the use of a pre-test probability (PTP) risk score (RS) which predicts the likelihood of coronary artery disease (CAD) to guide investigation and modality. The 2019 guidelines provide an updated PTPRS compared with 2013 guidelines, adjusted for the lower prevalence of coronary artery disease in contemporary populations. We assessed the performance of the two PTPRS in a cohort of patients with stable chest pain who underwent CT coronary angiography (CTCA) as the first line investigation. Methods We retrospectively searched a radiology database from January 2017 to June 2018. CTCA reported CAD degree of stenosis as normal/minimal stenosis, mild (30–50%), moderate (50–70%), or severe (&gt;70%) and retrospectively calculated ESC PTP scores for 2013 and 2019 guidelines. Results In total 652 patients underwent CTCA (mean age 55 yrs; IQR 48–63; 330 male). For ESC 2019 PTPRS there were no patients with PTP &gt;85%. 2 patients had PTP 50–85%; 1 patient had moderate stenosis and 1 mild stenosis on CTCA. 267 patients had PTP 15–50%; 23 (9%) had severe stenosis and 35 (13%) moderate stenosis. Finally, 379 patients had PTP &lt;15%; 11 (3%) had severe stenosis and 18 (5%) moderate CTCA stenosis. In comparison, ESC 2013 PTPRS had 2 patients with PTP &gt;85%; 1 had moderate stenosis and 1 had mild stenosis on CTCA. 149 patients had PTP 50–85%; 17 (11%) had severe stenosis and 23 (15%) moderate stenosis. A further 427 patients had a PTP 15–50%; 17 (4%) had severe stenosis and 32 (8%) had moderate stenosis. Lastly, 70 patients had a PTP &lt;15% and two (3%) were found to have a moderate stenosis on CTCA. Conclusions The updated ESC 2019 PTPRS appears to underestimate the presence of CAD given 11 (3%) patients with severe CTCA stenosis would have been missed. Although the 2013 PTPRS was thought to overestimate the prevalence of CAD, it did not miss anyone found to have severe CTCA stenosis. Furthermore, patients with evidence of mild or moderate CAD on CTCA may not have been investigated due to PTP &lt;15% and therefore may not be commenced on medical therapy, to derive a mortality benefit as demonstrated in SCOT-Heart trial. Funding Acknowledgement Type of funding source: None

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