Validation of the European Society of Cardiology pre-test probability model for obstructive coronary artery disease

2020 ◽  
Author(s):  
Simon Winther ◽  
Samuel Emil Schmidt ◽  
Laust Dupont Rasmussen ◽  
Luis Eduardo Juárez Orozco ◽  
Flemming Hald Steffensen ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
European Society ◽  
Probability Model ◽  
Invasive Coronary Angiography ◽  
Fractional Flow ◽  
Flow Reserve ◽  
Artery Disease ◽  
European Society Of Cardiology ◽  
Test Probability

Abstract Aims  Estimation of pre-test probability (PTP) of disease in patients with suspected coronary artery disease (CAD) is a common challenge. Due to decreasing prevalence of obstructive CAD in patients referred for diagnostic testing, the European Society of Cardiology suggested a new PTP (2019-ESC-PTP) model. The aim of this study was to validate that model. Methods and results  Symptomatic patients referred for coronary computed tomography angiography (CTA) due to suspected CAD in a geographical uptake area of 3.3 million inhabitants were included. The reference standard was a combined endpoint of CTA and invasive coronary angiography (ICA) with obstructive CAD defined at ICA as a ≥50% diameter stenosis or fractional flow reserve ≤0.80 when performed. The 2019-ESC-PTP, 2013-ESC-PTP, and CAD Consortium basic PTP scores were calculated based on age, sex, and symptoms. Of the 42 328 identified patients, coronary stenosis was detected in 8.8% using the combined endpoint. The 2019-ESC-PTP and CAD Consortium basic scores classified substantially more patients into the low PTP groups (PTP < 15%) than did the 2013-ESC-PTP (64% and 65% vs. 16%, P < 0.001). Using the combined endpoint as reference, calibration of the 2019-ESC-PTP model was superior to the 2013-ESC-PTP and CAD Consortium basic score. Conclusion  The new 2019-ESC-PTP model is well calibrated and superior to the previously recommended models in predicting obstructive stenosis detected by a combined endpoint of CTA and ICA.

scholarly journals Lesion left main coronary artery and / or multivessel coronary artery disease

2021 ◽  
pp. 28-32
Author(s):  
V. A. Skybchyk ◽  
Y. P. Melen
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Left Main Coronary Artery ◽  
Invasive Coronary Angiography ◽  
Myocardial Revascularization ◽  
Clinical Signs ◽  
Left Main ◽  
Fractional Flow ◽  
Flow Reserve ◽  
Artery Disease

The article describes the clinical and electrocardiograph|y features of the lesion left main coronary artery (LMCA). LMCA stenosis of more than 50% allows to classificated such patients as a high risk of sudden death, which occurs 3-4 times more often compared with coronary artery disease in other localizations. Another feature characteristic of this category of patients is the presence of multifocal atherosclerosis (MFA). In patients without carotid stenosis, LMCA lesions are detected in 5% of cases, while in patients with MFA (with lesions of the carotid arteries) - in 40%. Despite some clinical signs that allow the patient to suspect the presence of LMCA, the most informative and reliable method is invasive coronary angiography (CAG). Evaluation of CAG using fractional flow reserve (FFR) and intravascular ultrasound (IVUS) help to improve the diagnosis of the degree of LMCA stenosis, assess the nature of the plaque, the true diameter of the vessel and is an important step towards early myocardial revascularization. The article also presents the clinical analysis of lectrocardiogram with lesions of LMCA and multivessel lesions of the coronary arteries (three vessels or more).

scholarly journals Coronary artery stenosis-related perfusion ratio using dynamic computed tomography myocardial perfusion imaging: a pilot for identification of hemodynamically significant coronary artery disease

2019 ◽  
Vol 35 (4) ◽  
pp. 327-335 ◽  
Author(s):  
Natsumi Kuwahara ◽  
Yuki Tanabe ◽  
Teruhito Kido ◽  
Akira Kurata ◽  
Teruyoshi Uetani ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Diagnostic Performance ◽  
Invasive Coronary Angiography ◽  
Significant Coronary Artery Disease ◽  
Fractional Flow ◽  
Coronary Cta ◽  
Flow Reserve ◽  
Artery Disease

Abstract The purpose of this study was to evaluate the feasibility of the stenosis-related quantitative perfusion ratio (QPR) for detecting hemodynamically significant coronary artery disease (CAD). Twenty-seven patients were retrospectively enrolled. All patients underwent dynamic myocardial computed tomography perfusion (CTP) and coronary computed tomography angiography (CTA) before invasive coronary angiography (ICA) measuring the fractional flow reserve (FFR). Coronary lesions with FFR ≤ 0.8 were defined as hemodynamically significant CAD. The myocardial blood flow (MBF) was calculated using dynamic CTP data, and CT-QPR was calculated as the CT-MBF relative to the reference CT-MBF. The stenosis-related CT-MBF and QPR were calculated using Voronoi diagram-based myocardial segmentation from coronary CTA data. The relationships between FFR and stenosis-related CT-MBF or QPR and the diagnostic performance of the stenosis-related CT-MBF and QPR were evaluated. Of 81 vessels, FFR was measured in 39 vessels, and 20 vessels (51%) in 15 patients were diagnosed as hemodynamically significant CAD. The stenosis-related CT-QPR showed better correlation (r = 0.70, p < 0.05) than CT-MBF (r = 0.56, p < 0.05). Sensitivity and specificity for detecting hemodynamically significant CAD were 95% and 58% for CT-MBF, and 95% and 90% for CT-QPR, respectively. The area under the receiver operating characteristic curve for the CT-QPR was significantly higher than that for the CT-MBF (0.94 vs. 0.79; p < 0.05). The stenosis-related CT-QPR derived from dynamic myocardial CTP and coronary CTA showed a better correlation with FFR and a higher diagnostic performance for detecting hemodynamically significant CAD than the stenosis-related CT-MBF.

Pre-test probability prediction in patients with a low to intermediate probability of coronary artery disease: a prospective study with a fractional flow reserve endpoint

2019 ◽  
Vol 20 (11) ◽  
pp. 1208-1218 ◽  
Author(s):  
Simon Winther ◽  
Louise Nissen ◽  
Jelmer Westra ◽  
Samuel Emil Schmidt ◽  
Nadia Bouteldja ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Fractional Flow Reserve ◽  
Calcium Score ◽  
Receiver Operating Curve ◽  
Fractional Flow ◽  
Predictive Values ◽  
Flow Reserve ◽  
Artery Disease ◽  
Test Probability

Abstract Aims European and North American guidelines currently recommend pre-test probability (PTP) stratification based on simple probability models in patients with suspected coronary artery disease (CAD). However, no unequivocal recommendation has yet been established. We aimed to compare the ability of risk factors and different PTP stratification models to predict haemodynamically obstructive CAD with fractional flow reserve (FFR) as reference in low to intermediate probability patients. Methods and results We prospectively included 1675 patients with low to intermediate risk who had been referred to coronary computed tomography angiography (CTA). Patients with coronary stenosis were subsequently investigated by invasive coronary angiography (ICA) with FFR measurement if indicated. Discrimination and calibration were assessed for four models: the updated Diamond–Forrester (UDF), the CAD Consortium Basic, the Clinical, and the Clinical + Coronary artery calcium score (CACS). At coronary CTA, 24% of patients were diagnosed with a suspected stenosis and 10% had haemodynamically obstructive CAD at the ICA. Calibration for all CAD Consortium models increased compared with the UDF score. However, all models overestimated the probability of haemodynamically obstructive CAD. Discrimination increased by area under the receiver operating curve from 67% to 86% for UDF vs. CAD Consortium Clinical + CACS. The proportion of low-probability patients (pre-test score < 15%) was for the UDF, CAD Consortium Basic, Clinical, and Clinical + CACS: 14%, 58%, 51%, and 66%, respectively. The corresponding negative predictive values were 97%, 94%, 95%, and 98%, respectively. Conclusion CAD Consortium models improve PTP stratification compared with the UDF score, mainly due to superior calibration in low to intermediate probability patients. Adding the coronary calcium score to the models substantially increases discrimination. Clinical Trials. gov identifier NCT02264717.

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.

P2721FFRct analysis for screening of obstructive coronary artery disease: a propensity score adjusted study

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
J.-F Argacha ◽  
B Vandeloo ◽  
T Mizukami ◽  
K Tanaka ◽  
D Belsack ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Propensity Score ◽  
Stress Test ◽  
Invasive Coronary Angiography ◽  
Real Life ◽  
Fractional Flow ◽  
Flow Reserve ◽  
Artery Disease ◽  
The Impact

Abstract Background Guidelines recommend functional assessment in stable coronary artery disease (CAD) to guide further treatment. Computed tomography fractional flow reserve (FFRCT) has been proposed for non-invasive assessment of stable CAD. A cutoff value of FFRCT ≥0.8 has been shown cost-effective, and allowing to avoid inappropriate invasive coronary angiography (ICA). However, no results from real-life hospital registries have been reported yet. Purpose We aimed to compare the impact of FFRCT with conventional coronary CT angiography (CTA) for detecting obstructive CAD in the daily practice of a tertiary referral hospital. Methods Patients referred to CTA for suspected CAD between 2013 and 2017 were included. FFRCT analysis was introduced in 2015 and performed at the discretion of the radiologist by Heartflow Inc. FFRCT was considered abnormal if FFR was <0.8 in at least one of 3 main vessels. Obstructive CAD was defined on both CTA and ICA by the presence of a stenosis ≥50% in at least one of 3 main vessels, or an invasive FFR<0.8. Propension to perform a FFRCT was modeled, based on gender, cardiovascular risk factors, completion of stress test and echocardiography and presence of a lesion of more than 50% stenosis on CTA. A logistic regression adjusted for the propensity score was then performed on the use of ICA, the presence of significant CAD on ICA and revascularization rate either by PCI or CABG. Results 2906 patients (50% of male, 56±12) were included in this registry. Diabetes, hypertension, dyslipidemia and smoking were present in respectively 12.3, 30.5, 27.5 and 9% of patients. A stress ECG and a transthoracic echo were obtained in respectively 37.1 and 49% of patients. FFRCT was performed in 757 (26%) and was abnormal in 323 (42.7%) of the patients. An ICA was performed in 622 (21.4%) patients and was abnormal in 292 (46.9%). After propensity score weighting, FFRCT was associated with an increase in ICA (OR=1.58, 95% CI: 1.23–2.02, p<0.01). There were no significant changes regarding ICA showing obstructive CAD with FFRCT (OR=1.13, 95% CI: 0.78–1.66, p=0.5) but a trend towards an increase of revascularization (OR=1.48, 95% CI: 0.98–2.24, p=0.06). In patient undergoing an ICA, a FFRCT ≥0.8 was decreasing the presence of significant CAD (OR=0.27, 95% CI: 0.16–0.48, p<0.001), whereas a FFRCT <0.8 increased the rate of revascularization (OR=24.7, 95% CI: 12.3–49.7, p<0.001). Conclusion These real life data showed that, adding FFRCT to conventional CTA, and interpreting only the numerical values of FFRCT, would increase the use of ICA in patients suspected of CAD. A trend towards an increase in revascularization was also observed. Therefore, another index than the minimal FFRCT should be used to improve discrimination regarding the presence of obstructive CAD. However, normal values of FFRCT were strong predictors of the absence of significant CAD, and abnormal values of FFRCT for the need of a revascularization.

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