A 10-year prognostic model for patients with suspected angina attending a chest pain clinic

Abstract

Background and objectiveDiagnostic models used in the management of suspected angina provide no explicit information about prognosis. We present a new prognostic model of 10-year coronary mortality in patients presenting for the first time with suspected angina to complement the Diamond-Forrester diagnostic model of disease probability.Methods and resultsA multicentre cohort of 8762 patients with suspected angina was followed up for a median of 10 years during which 233 coronary deaths were observed. Developmental (n=4412) and validation (n=4350) prognostic models based on clinical data available at first presentation showed good performance with close agreement and the final model utilised all 8762 patients to maximise power. The prognostic model showed strong associations with coronary mortality for age, sex, chest pain typicality, smoking status, diabetes, pulse rate, and ECG findings. Model discrimination was good (C statistic 0.83), patients in the highest risk quarter accounting for 173 coronary deaths (10-year risk of death: 8.7%) compared with a total of 60 deaths in the three lower risk quarters. When the model was simplified to incorporate only Diamond-Forrester factors (age, sex and character of symptoms) it underestimated coronary mortality risk, particularly in patients with reversible risk factors.ConclusionsFor the first time in patients with suspected angina, a prognostic model is presented based on simple clinical factors available at the initial cardiological assessment. The model discriminated powerfully between patients at high risk and lower risk of coronary death during 10-year follow-up. Clinical utility was reflected in the prognostic value it added to the updated Diamond-Forrester diagnostic model of disease probability.

National Institute for Health and Care Excellence updates the stable chest pain guideline with radical changes to the diagnostic paradigm

“…Now, indirect observations suggest that the Genders updated disease estimates, recommended in the European Society of Cardiology guideline, may be similarly unreliable. Thus, a recent study found that patients with disease estimates as high as 60%–90% (mean 74%) had an annualised coronary mortality rate of only 0.7% 15. This apparent mismatch between predicted disease and observed mortality emphasises the likely unreliability of the disease estimates and the importance of considering prognostic indicators in patients with suspected angina so that those at greatest risk might be identified.…”

“…This apparent mismatch between predicted disease and observed mortality emphasises the likely unreliability of the disease estimates and the importance of considering prognostic indicators in patients with suspected angina so that those at greatest risk might be identified. The Prognosis In Suspected Angina model based on simple clinical factors available at the initial cardiological assessment has been internally validated in a large chest pain clinic cohort and shows strong associations with coronary mortality (c-statistic 0.83) 15. A desktop calculator is available and promises to emerge as an important clinical tool if further validation studies are favourable.…”

“…Meanwhile, NICE predicts that its updated recommendations will lead to considerable annual savings for the population of England, estimates increasing from £6.8 million in 2017/2018 to £17 million in 2020/2021, assuming a complete shift from previously recommended testing strategies to CTCA testing, with 20% of patients going on to have a non-invasive functional test and a further 10% receiving diagnostic invasive coronary angiography. This calculation is based on contemporary National Health Service (NHS) tariffs or recent reference costs and includes modelling for the costs of potential complications of the procedures,48 49 with numbers of patients attending a rapid access chest pain clinic in England each year around 1 20 00050 and pretest probability of CAD proportions derived from recently published data 15. These savings are important given the substantial healthcare utilisation and costs incurred by patients with stable CAD,51 but caution is required in extrapolating the calculated savings to non-UK settings.…”

Simple risk models to predict cardiovascular death in patients with stable coronary artery disease

“… 4 Since CV event rates have been falling, a successful risk model must reflect contemporary risk. Risk models have been developed for patients with stable CAD, some derived for specific subpopulations such as patients with anginal symptoms, 5–7 patients with suspected angina attending a chest pain clinic, 8 survivors of acute coronary syndromes, 9 populations including less stable participants with recent myocardial infarction (MI), 10 and patients recruited to clinical trials. 9–11 Many of these models do not reflect current clinical practice or absolute CV risk.…”

Avaliação prognóstica no seguimento de longo prazo dos pacientes submetidos a angiotomografia de coronárias: sub análise dos estudos CORE64 e CORE320

“…Outros escores como o CAD consortium (7) e o Diamond Forrester (8) são utilizados para predizer doença arterial coronária obstrutiva no paciente com dor torácica. Sekhri et al (9) publicaram um modelo de prognóstico em 10 anos para pacientes com suspeita de angina que se apresenta com dor torácica.…”