High probability of disease in angina pectoris patients: Is clinical estimation reliable?

Høilund-Carlsen, Poul Fl.; Johansen, Allan; Vach, Werner; Christensen, Henrik Wulff; Møldrup, Mette; Haghfelt, Torben

doi:10.1016/s0828-282x(07)70226-x

Cited by 18 publications

(8 citation statements)

References 35 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Hoilund-Carlsen, et al found absence of CAD50 in 97 (52%) of 187 men and women with TypAng and a mean age of 58 years. 24 Guideline Probabilities predicted >80% prevalence in this population, leading the authors to conclude that clinical prediction was unreliable. Patel, et al, in over 130,000 patients with TypAng from the American College of Cardiology National Cardiovascular Data Registry, observed an overall CAD50 prevalence of 50%.…”

Section: Discussionmentioning

confidence: 93%

Performance of the Traditional Age, Sex, and Angina Typicality–Based Approach for Estimating Pretest Probability of Angiographically Significant Coronary Artery Disease in Patients Undergoing Coronary Computed Tomographic Angiography

et al. 2011

View full text Add to dashboard Cite

Background Guidelines for the management of patients with suspected coronary artery disease (CAD) rely on the age, sex, and angina typicality-based pre-test probabilities of angiographically significant CAD derived from invasive coronary angiography (“Guideline Probabilities”). Reliability of Guideline Probabilities has not been investigated in patients referred to noninvasive CAD testing. Methods and Results We identified 14048 consecutive patients with suspected CAD who underwent coronary computed tomographic angiography (CTA) Angina typicality was recorded using accepted criteria. Pre-test likelihoods of CAD with ≥50% diameter stenosis (CAD50) and ≥70% diameter stenosis (CAD70) were calculated using Guideline Probabilities. CTA images were evaluated by ≥1 expert reader to determine presence of CAD50 and CAD70. Typical angina was associated with the highest prevalence of CAD50 (40% in men, 19% in women) and CAD70 (27% men, 11% women) when compared to other symptom categories (p<0.001 for all). Observed CAD50 and CAD70 prevalence were substantially lower than that predicted by Guideline Probabilities in the overall population (18% vs. 51% for CAD50, 10% vs. 42% for CAD70, p<0.001), driven by pronounced differences in patients with atypical angina (15% vs. 47% for CAD50, 7% vs. 37% for CAD70) and typical angina (29% vs. 86% for CAD50, 19% vs. 71% for CAD70). Marked overestimation of disease prevalence by Guideline Probabilities was found at all participating centers and across all sex and age subgroups. Conclusion In this multinational study of patients referred for coronary CTA, determination of pre-test likelihood of angiographically significant CAD by the invasive angiography-based Guideline Probabilities greatly overestimates the actual prevalence of disease.

show abstract

Section: Discussionmentioning

confidence: 93%

Performance of the Traditional Age, Sex, and Angina Typicality–Based Approach for Estimating Pretest Probability of Angiographically Significant Coronary Artery Disease in Patients Undergoing Coronary Computed Tomographic Angiography

et al. 2011

View full text Add to dashboard Cite

show abstract

“…It may be related to a contemporary lower prevalence of CAD as compared with the historic cohorts that served as the base for the development of that model . Even though CAD1 is an updated version of the original DF method, which was shown to overestimate the probability of CAD in patients referred to ICA or noninvasive tests, it still overestimated the prevalence of CAD in our population. Recently, the same was shown by Zorlak et al in patients referred to ICA or noninvasive testing .…”

Section: Discussionmentioning

confidence: 93%

Comparison of Coronary Artery Disease Consortium 1 and 2 Scores and Duke Clinical Score to Predict Obstructive Coronary Disease by Invasive Coronary Angiography

Almeida

Fonseca

Dias

et al. 2016

Clinical Cardiology

View full text Add to dashboard Cite

Background The first step in evaluating a patient with suspected stable coronary artery disease (CAD) is the determination of the pretest probability. The European Society of Cardiology guidelines recommend the use of the CAD Consortium 1 score (CAD1), which contrary to CAD Consortium 2 (CAD2) score and Duke Clinical Score (DCS), does not include modifiable cardiovascular risk factors. Hypothesis Using scores that include modifiable risk factors (DCS and CAD2) enhances prediction of CAD. Methods We retrospectively included all patients referred to invasive coronary angiography for suspected CAD from January/2008–December/2012 (N = 2234). Pretest probability was calculated using 3 models (CAD1, DCS, and CAD2), and they were compared using the net reclassification improvement. Results Mean patient age was 63.7 years, 67.5% were male, and the majority (66.9%) had typical angina. Coronary artery disease was diagnosed in 58.5%, and the area under the curve was 0.685 for DCS, 0.664 for CAD1, and 0.683 for CAD2, with a statistically significant difference between CAD1 and the others (P < 0.001). The net reclassification improvement was 20% for DCS, related to adequate reclassification of 32% of patients with CAD to a higher risk category, and 5% for CAD2, at the cost of adequate reclassification of 34% of patients without CAD to a lower risk category. Conclusions Prediction of CAD using scores that include modifiable cardiovascular risk factors seems to improve accuracy. Our results suggest that, in high‐prevalence populations, DCS may better identify patients at higher risk and CAD2 those at lower risk for CAD.

show abstract

“…Indeed, previous research has shown that general practitioners have only moderate diagnostic accuracy when estimating the likelihood of coronary artery disease in their patients8 and the gestalt of cardiologists is unreliable for predicting findings at coronary angiography 9. However, the judgement of the treating physician has been shown to have independent diagnostic value in patients with suspected deep vein thrombosis and pulmonary embolism and is an important component of widely used clinical decision rules for those diagnoses 10 11.…”

Section: Introductionmentioning

confidence: 99%

Can emergency physicians ‘rule in’ and ‘rule out’ acute myocardial infarction with clinical judgement?

et al. 2014

View full text Add to dashboard Cite

ObjectiveTo determine the diagnostic accuracy of emergency physician gestalt in emergency department (ED) patients with suspected cardiac chest pain, both alone and in combination with initial troponin level and ECG findings.MethodsWe prospectively included patients presenting to the ED with suspected cardiac chest pain. Clinicians recorded their ‘gestalt’ at the time of presentation using a five-point Likert scale, blinded to outcome. Troponin T and high-sensitivity troponin T (hs-cTnT; both Roche Diagnostics Elecsys) levels were measured in admission blood samples. All patients underwent troponin testing at least 12 h after peak symptoms. The primary outcome was acute myocardial infarction (AMI).Results458 patients were included in this study, 81 (17.7%) of whom had AMI. Clinician gestalt alone had an area under the receiver operating characteristic curve of 0.76 (95% CI 0.70 to 0.82) for AMI. Immediately discharging patients with normal initial troponin and ECG in whom the clinician felt the diagnosis was ‘probably not’ or ‘definitely not’ acute coronary syndrome (ACS) would have avoided admission for 23.1% (95% CI 19% to 28%) patients with 100% sensitivity (95% CI 95.6% to 100%). With hs-cTnT, 100% sensitivity could have been achieved even if only patients with ‘probable’ or ‘definite’ ACS were investigated further, which would have allowed 41.7% patients to be discharged immediately.ConclusionsGestalt alone cannot be used to ‘rule in’ or ‘rule out’ ACS. By combining clinician gestalt with the admission ECG and troponin level, we found 100% sensitivity without the need for serial troponin testing. These findings have the potential to reduce unnecessary hospital admissions for suspected ACS but must be prospectively validated before considering clinical implementation.

show abstract

High probability of disease in angina pectoris patients: Is clinical estimation reliable?

Cited by 18 publications

References 35 publications

Performance of the Traditional Age, Sex, and Angina Typicality–Based Approach for Estimating Pretest Probability of Angiographically Significant Coronary Artery Disease in Patients Undergoing Coronary Computed Tomographic Angiography

Performance of the Traditional Age, Sex, and Angina Typicality–Based Approach for Estimating Pretest Probability of Angiographically Significant Coronary Artery Disease in Patients Undergoing Coronary Computed Tomographic Angiography

Comparison of Coronary Artery Disease Consortium 1 and 2 Scores and Duke Clinical Score to Predict Obstructive Coronary Disease by Invasive Coronary Angiography

Can emergency physicians ‘rule in’ and ‘rule out’ acute myocardial infarction with clinical judgement?

Contact Info

Product

Resources

About