Prediction of obstructive coronary artery disease and prognosis in patients with suspected stable angina

Abstract

Aims We hypothesized that the modified Diamond–Forrester (D-F) prediction model overestimates probability of coronary artery disease (CAD). The aim of this study was to update the prediction model based on pre-test information and assess the model’s performance in predicting prognosis in an unselected, contemporary population suspected of angina. Methods and results We included 3903 consecutive patients free of CAD and heart failure and suspected of angina, who were referred to a single centre for assessment in 2012–15. Obstructive CAD was defined from invasive angiography as lesion requiring revascularization, >70% stenosis or fractional flow reserve <0.8. Patients were followed (mean follow-up 33 months) for myocardial infarction, unstable angina, heart failure, stroke, and death. The updated D-F prediction model overestimated probability considerably: mean pre-test probability was 31.4%, while only 274 (7%) were diagnosed with obstructive CAD. A basic prediction model with age, gender, and symptoms demonstrated good discrimination with C-statistics of 0.86 (95% CI 0.84–0.88), while a clinical prediction model adding diabetes, family history, and dyslipidaemia slightly improved the C-statistic to 0.88 (0.86–0.90) (P for difference between models <0.0001). Quartiles of probability of CAD from the clinical prediction model provided good diagnostic and prognostic stratification: in the lowest quartiles there were no cases of obstructive CAD and cumulative risk of the composite endpoint was less than 3% at 2 years. Conclusion The pre-test probability model recommended in current ESC guidelines substantially overestimates likelihood of CAD when applied to a contemporary, unselected, all-comer population. We provide an updated prediction model that identifies subgroups with low likelihood of obstructive CAD and good prognosis in which non-invasive testing may safely be deferred.

Validation of European Society of Cardiology pre-test probabilities for obstructive coronary artery disease in suspected stable angina

“…All recruiting centres in PROMISE were in North America. Reeh et al 4 retrospectively assessed 3903 patients who underwent invasive angiography at a single Danish centre for investigation of suspected angina. Most patients had already undergone at least one other test prior to angiography.…”

“…The guideline has updated estimation of pre-test probability for obstructive coronary artery disease based on chest pain type, age, and gender using more contemporaneous data from the Coronary CT Angiography Evaluation For Clinical Outcomes: An International Multicenter (CONFIRM) Registry, the CT group of the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) randomized controlled trial and a retrospective single-centre angiographic cohort. 1 , 3 , 4 , 6 The thresholds that warrant further downstream testing have also been revised such that patients with a pre-test probability <5% are not recommended to undergo further testing, while testing is deemed appropriate in those with a pre-test probability >15%. Patients with an intermediate pre-test probability of 5–15% are recognized to have a good prognosis and testing may safely be deferred, although discretionary investigation can have a role.…”

Association between cardiovascular risk factors and coronary artery disease assessed using CAD-RADS classification: a cross-sectional study in Romanian population

“…Our results are in concordance with the latest data from the European Heart Network which shows that systolic blood pressure and total cholesterol levels are the determinants with the greatest contribution to CVD mortality 17. Also, these two factors are included in the widely used SCORE charts (3), and there are many clinical models that add them for increasing the probability of obstructive CAD 36–39…”

ESC 2019 guidelines for the diagnosis and management of chronic coronary syndromes

“…Studies have shown that an outcome in patients with the new PTP of up to 15% is good (annual risk of cardiovascular death or myocardial infarction [MI] <1%; [ 8 , 9 ]). Hence, it would be safe to defer routine testing in patients with PTP <15%, thus reducing unnecessary procedures.…”