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

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 (>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 >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 <15%; 11 (3%) had severe stenosis and 18 (5%) moderate CTCA stenosis. In comparison, ESC 2013 PTPRS had 2 patients with PTP >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 <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 <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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MRI perfusion in patients with stable chest-pain

British Journal of Radiology ◽

10.1259/bjr.20190881 ◽

2020 ◽

Vol 93 (1113) ◽

pp. 20190881 ◽

Cited By ~ 1

Author(s):

Marly van Assen ◽

Dirk Jan Kuijpers ◽

Juerg Schwitter

Keyword(s):

Coronary Artery Disease ◽

Chest Pain ◽

Coronary Artery ◽

Cardiac Events ◽

Non Invasive ◽

Cardiovascular Mr ◽

Esc Guidelines ◽

Artery Disease ◽

Stable Chest Pain ◽

Cmr Imaging

Perfusion-cardiovascular MR (CMR) imaging has been shown to reliably identify patients with suspected or known coronary artery disease (CAD), who are at risk for future cardiac events and thus, allows for guiding therapy including revascularizations. Accordingly, it is an ideal test to exclude prognostically relevant coronary artery disease. Several guidelines, such as the ESC guidelines, currently recommend CMR as non-invasive testing in patients with stable chest pain. CMR has as an advantage over the more conventional pathways as it lacks radiation and it potentially reduces costs.

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

European Radiology ◽

10.1007/s00330-020-07175-z ◽

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.

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ESC 2019 guidelines on chronic coronary syndromes: can calcium scoring improve the risk underestimation associated with the updated pre-test probability risk score?

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeaa356.233 ◽

2021 ◽

Vol 22 (Supplement_1) ◽

Author(s):

S Fyyaz ◽

H Rasoul ◽

O Olabintan ◽

S David ◽

S Plein ◽

...

Keyword(s):

Chest Pain ◽

Risk Score ◽

Calcium Score ◽

Low Risk ◽

Risk Scores ◽

Severe Stenosis ◽

Mild Stenosis ◽

Number Of Patients ◽

Stable Chest Pain ◽

Test Probability

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The European Society of Cardiology (ESC) published an updated stable chest pain guideline in 2019. It recommends the use of an updated pre-test probability (PTP) risk score (RS) to assess the likelihood of coronary artery disease (CAD), to try and reduce the risk overestimation associated with previous risk scores. We sought to assess the performance of the 2019 PTPRS in a contemporary cohort of patients undergoing CT coronary angiography (CTCA). Furthermore, we focussed on patients with PTPRS <15%, and assessed the utility of CT calcium scores as a discriminator of risk. Methods 652 patients who were investigated with CTCA for stable chest pain between January 2017 and May 2018 were included in a retrospective analysis. CTCA reported CAD degree of stenosis as normal/minimal stenosis, mild (30-50%), moderate (50-70%), or severe (>70%). ESC 2019 pre-test probability risk scores were retrospectively calculated and compared. Results A total of 652 patients underwent CTCA between 01 January 2017 and 31 May 2018, of which 330 were male and 322 were female, with an average age of 55 years ±11 years. Using the ESC 2019 PTPRS there were no patients with PTPRS >85%. 2 patients had PTPRS 50-85%; one patient had moderate stenosis and one mild stenosis on CTCA. There were 267 patients with PTPRS 15-50%; 23 (9%) patients had severe CTCA stenosis, 37 (14%) a moderate stenosis, and 34 (13%) a mild stenosis. A further 379 patients had PTPRS <15%; 11 (3%) had severe stenosis and 20 (5%) moderate stenosis. A further 27 (7%) patients had mild CTCA stenosis. A total of 357 of 379 patients with PTPRS <15% based on ESC 2019 had a CT calcium score. 236 patients were found to have a calcium score of zero, and 121 patients had a score greater than zero, with a range between 1 and 930. Of patients with zero calcium score, only 1 (0.4%) patient had severe stenosis, 2 (0.8%) moderate stenoses and 6 (2.5%) mild stenosis. In contrast, in patients with positive calcium scores, 10 (8%) had severe stenosis, 18 (15%) moderate stenosis, and 22 (18%) mild stenosis. Conclusions The ESC 2019 PTPRS classified this as an overall low risk cohort. The downward risk modification of PTPRS has led to a large number of patients being classified as low risk with PTPRS <15%. No or deferred investigation is recommended by the ESC in this cohort. However, the use of CT calcium scores in patients with PTPRS <15%, detected the majority of patients with any degree of CAD. CT calcium scores are a simple and low cost risk modifier, and may help identify patients who may benefit from primary prevention as per SCOT-Heart. Patients with calcium score greater than zero could be investigated with CTCA.

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A Comparison of the Updated Diamond-Forrester, CAD Consortium, and CONFIRM History-Based Risk Scores for Predicting Obstructive Coronary Artery Disease in Patients With Stable Chest Pain

JACC Cardiovascular Imaging ◽

10.1016/j.jcmg.2018.02.020 ◽

2019 ◽

Vol 12 (7) ◽

pp. 1392-1400 ◽

Cited By ~ 13

Author(s):

Lohendran Baskaran ◽

Ibrahim Danad ◽

Heidi Gransar ◽

Bríain Ó Hartaigh ◽

Joshua Schulman-Marcus ◽

...

Keyword(s):

Coronary Artery Disease ◽

Chest Pain ◽

Coronary Artery ◽

Obstructive Coronary Artery Disease ◽

Risk Scores ◽

Artery Disease ◽

Stable Chest Pain ◽

Diamond Forrester

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110 THE FEASIBILITY OF USING CT CORONARY ANGIOGRAPHY IN PATIENTS WITH STABLE CHEST PAIN AND MODERATE TO HIGH PRE-TEST PROBABILITY OF CORONARY ARTERY DISEASE

Heart ◽

10.1136/heartjnl-2013-304019.110 ◽

2013 ◽

Vol 99 (suppl 2) ◽

pp. A68.1-A68

Author(s):

A Cai ◽

P Dobson ◽

P Leung ◽

K Marshall ◽

M Albarjas ◽

...

Keyword(s):

Coronary Artery Disease ◽

Chest Pain ◽

Coronary Artery ◽

Coronary Angiography ◽

Ct Coronary Angiography ◽

Artery Disease ◽

Stable Chest Pain ◽

Test Probability

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

European Heart Journal ◽

10.1093/ehjci/ehaa946.1380 ◽

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 <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 <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

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