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 <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

scholarly journals Incorporating coronary calcification into pretest assessment of the likelihood of coronary artery disease: validation and recalibration of a new diagnostic tool

2021 ◽  
Vol 22 (Supplement_3) ◽  
Author(s):  
P Lopes ◽  
J Presume ◽  
P Araujo Goncalves ◽  
F Albuquerque ◽  
P Freitas ◽  
...  
Keyword(s):  
Risk Factors ◽  
Coronary Artery Disease ◽  
Chest Pain ◽  
Coronary Artery ◽  
Prediction Model ◽  
Obstructive Coronary Artery Disease ◽  
P Value ◽  
Discrimination Power ◽  
Coronary Syndrome ◽  
Artery Disease

Abstract Funding Acknowledgements Type of funding sources: None. Background A new clinical tool was recently proposed to improve the estimation of pre-test probability of obstructive coronary artery disease (CAD) by incorporating coronary artery calcium score (CACS) with clinical risk factors. This new model (Clinical + CACS) showed improved prediction when compared to the method recommended by the 2019 ESC guidelines on chronic coronary syndromes, but was never tested or adjusted for use in our population. The aim of this study was to assess the performance of this new method in a Portuguese cohort of symptomatic patients referred for coronary computed tomography angiography (CCTA), and to recalibrate it if necessary. Methods We conducted a two-center cross-sectional study assessing symptomatic patients who underwent CCTA for suspected CAD. Key exclusion criteria were age < 30 years, known CAD, suspected acute coronary syndrome, or symptoms other than chest pain or dyspnea. Obstructive CAD was defined as any luminal stenosis ≥50% on CCTA. The Clinical + CACS prediction model was assessed for discrimination and calibration. A logistical recalibration of the model was conducted in a random sample of 50% of the patients and subsequently validated in the other half. Results A total of 1910 patients (mean age 60 ± 11 years, 60% women) were included in the analysis. Symptom characteristics were: 39% non-anginal chest pain, 30% atypical angina, 19% dyspnea and 12% typical angina. The observed prevalence of obstructive CAD was 12.9% (n = 247). Patients with obstructive CAD were more often male, were significantly older, had higher prevalence of typical angina and cardiovascular risk factors, and higher CACS values. The new Clinical + CACS tool showed greater discriminative power than the ESC 2019 prediction model, with a C-statistic of 0.83 (CI 95% 0.81-0.86) versus 0.67 (CI 95% 0.64-0.71), respectively (p-value for comparison < 0.001). Before recalibration, the Clinical + CACS model underestimated the likelihood of CAD in our population across all quartiles of pretest probability (mean relative underestimation of 49%), which was subsequently corrected by the recalibration procedure - Figure. Conclusions In a Portuguese cohort of symptomatic patients undergoing CCTA for suspected CAD, the new Clinical + CACS model showed better discrimination power than the 2019 ESC method. The underestimation of the Clinical + CACS model was corrected by recalibrating it for our population. This new tool might prove useful for guiding decisions on the need for further testing.

scholarly journals Incorporating coronary calcification into pretest assessment of the likelihood of coronary artery disease: validation and recalibration of a new diagnostic tool

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
P Lopes ◽  
J Presume ◽  
P A Goncalves ◽  
F Albuquerque ◽  
P Freitas ◽  
...  
Keyword(s):  
Risk Factors ◽  
Coronary Artery Disease ◽  
Chest Pain ◽  
Coronary Artery ◽  
Prediction Model ◽  
Obstructive Coronary Artery Disease ◽  
P Value ◽  
Discrimination Power ◽  
Coronary Syndrome ◽  
Artery Disease

Abstract Background A new clinical tool was recently proposed to improve the estimation of pre-test probability of obstructive coronary artery disease (CAD) by incorporating coronary artery calcium score (CACS) with clinical risk factors. This new model (Clinical+CACS) showed improved prediction when compared to the method recommended by the 2019 ESC guidelines on chronic coronary syndromes, but was never tested or adjusted for use in our population. The aim of this study was to assess the performance of this new method in a Portuguese cohort of symptomatic patients referred for coronary computed tomography angiography (CCTA), and to recalibrate it if necessary. Methods We conducted a two-center cross-sectional study assessing symptomatic patients who underwent CCTA for suspected CAD. Key exclusion criteria were age <30 years, known CAD, suspected acute coronary syndrome, or symptoms other than chest pain or dyspnea. Obstructive CAD was defined as any luminal stenosis ≥50% on CCTA. The Clinical+CACS prediction model was assessed for discrimination and calibration. A logistical recalibration of the model was conducted in a random sample of 50% of the patients and subsequently validated in the other half. Results A total of 1910 patients (mean age 60±11 years, 60% women) were included in the analysis. Symptom characteristics were: 39% non-anginal chest pain, 30% atypical angina, 19% dyspnea and 12% typical angina. The observed prevalence of obstructive CAD was 12.9% (n=247). Patients with obstructive CAD were more often male, were significantly older, had higher prevalence of typical angina and cardiovascular risk factors, and higher CACS values. The new Clinical+CACS tool showed greater discriminative power than the ESC 2019 prediction model, with a C-statistic of 0.83 (CI 95% 0.81–0.86) versus 0.67 (CI 95% 0.64–0.71), respectively (p-value for comparison <0.001). Before recalibration, the Clinical+CACS model underestimated the likelihood of CAD in our population across all quartiles of pretest probability (mean relative underestimation of 49%), which was subsequently corrected by the recalibration procedure - Figure. Conclusions In a Portuguese cohort of symptomatic patients undergoing CCTA for suspected CAD, the new Clinical+CACS model showed better discrimination power than the 2019 ESC method. The underestimation of the Clinical+CACS model was corrected by recalibrating it for our population. This new tool might prove useful for guiding decisions on the need for further testing. FUNDunding Acknowledgement Type of funding sources: None.

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 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

scholarly journals Stable Angina Pectoris: One-Year Outcomes of Patients with Obstructive Coronary Artery Disease: Multicenter Sutdy in Dakar (Senegal)

2022 ◽  
Vol 5 (1) ◽  
pp. 01-07
Author(s):  
Paul Coffi HESSOU ◽  
Joseph Salvador MINGOU ◽  
Maboury DIAO ◽  
Fatou AW LEYE ◽  
Mouhamadou Bamba NDIAYE ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Chest Pain ◽  
Coronary Artery ◽  
Angina Pectoris ◽  
Stable Angina ◽  
Obstructive Coronary Artery Disease ◽  
Artery Disease ◽  
Stable Chest Pain ◽  
One Year

Background: CAD management is important in prevention of disease progression. But we have very little study or research on the evolution of stable angina in amulatory patients without coronary antecedents and with obstructive coronary disease. Purpose: The objective of our study was to analyze the clinical and angiographic profil of patients with stable chest pain and to assess their angina status one year outcomes. Patients and methods: All patients who presented with symptomatic angina pectoris and/or signs of ischemia and first diagnosis of obstructive CAD in the Cardiology Departments of Idrissa Pouye General Hospital and Aristide Le Dantec National University Hospital Center of Dakar, from March 01, 2019 to December 31, 2020 were selected. The clinical characteristics, initial angiographic findings, therapeutic strategy and outcome within the first year were analyzed. Results: During the study period, 84 outpatients presenting with symptomatic stable chest pain and first obstructive coronary artery disease were selected. The mean age was 63.01± 9.37 years. Male preponderance was observed with 63(75%) patients; Clinical symptoms were dominated by typical pain with 46.4% (n=39) ; the risk factors were dominated by hypertension 61.9% (n=52); diabetes 41.7% (n=35) and dyslipidemia 33.3% (n=28). During follow-up, 10 patients (11.90%) remained untraceable while 9 patients (10.71%) were not available for check-up; 3 patients (3.57%) died during follow-up. Only 62 patients (73.80) could be evaluated; among those who were alive and controlled, 26 patients (41.93%) with angina at baseline still had angina symptoms, 2 patients (3.22%) had undergone myocardial infarction; one (1.61%) had undergone urgent revascularization; one (1.61%) patient developed heart failure. Finally 32 patients (51.61%) were event-free and angina-free Conclusion: The management of outpatients with stable chest pain and first obstructive CAD appears favourable, with good adherence to guideline-based therapies one year outcomes. Stable chest pain is not associated with an increased risk for adverse cardiovascular outcomes but there remains room for improvement in terms of risk factor control.

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