Pretest probability for patients with suspected obstructive coronary artery disease: re-evaluating Diamond–Forrester for the contemporary era and clinical implications: insights from the PROMISE trial

Foldyna, Borek; Udelson, James E.; Karády, Júlia; Banerji, Dahlia; Lu, Michael T.; Mayrhofer, Thomas; Bittner, Daniel O.; Meyersohn, Nandini M.; Emami, Hamed; Genders, Tessa S. S.; Fordyce, Christopher B.; Ferencik, Maros; Douglas, Pamela S.; Hoffmann, Udo

doi:10.1093/ehjci/jey182

Cited by 109 publications

(92 citation statements)

References 24 publications

(33 reference statements)

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“…The study population of Cheng et al was also characterised by a relatively low prevalence of disease of 15%. The recently published study of Foldyna et al showed overestimation of the D+F model in a large multi-centric cohort from the PROMISE trial [26]. This is in accordance with the results of our study.…”

Section: Comparison With Other Studiessupporting

confidence: 94%

Clinical pre-test probability for obstructive coronary artery disease: insights from the European DISCHARGE pilot study

et al. 2020

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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.

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Section: Comparison With Other Studiessupporting

confidence: 94%

Clinical pre-test probability for obstructive coronary artery disease: insights from the European DISCHARGE pilot study

et al. 2020

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“…Although these patients had suspected coronary artery disease and underwent CTCA, only 8106 reported non-anginal chest pain, atypical angina, or typical anginal symptoms; this was the subgroup included in the pooled analysis. Foldyna et al 3 consisted of 4415 patients from the CT cohort of the randomized PROMISE trial, which tested functional testing against CTCA in symptomatic outpatients in whom physicians felt diagnostic testing for coronary artery disease was indicated. 13 One-quarter of patients did not have chest pain as the presenting symptom, and of those that did, only 12% had typical angina.…”

Section: Discussionmentioning

confidence: 99%

“…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.…”

Section: Introductionmentioning

confidence: 99%

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

Bing

Singh

Dweck

et al. 2020

European Heart Journal - Quality of Care and Clinical Outcomes

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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 >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 >15% compared to those at 5–15% and <5% (4.1%, 1.5%, and 1.4%, respectively, P < 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 >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.

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“…However, if diagnostic testing was deferred in patients with new PTP <15%, this would result in a large increase in the proportion of patients in whom diagnostic testing is not recommended. In data derived from the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial, 50% of patients previously classified as having an intermediate PTP of obstructive CAD were reclassified to a PTP <15% according to the new PTP [ 8 ]. In data derived from the pooled analysis [ 6 ], 57% of all patients had a PTP <15%.…”

Section: Ptp and Clinical Likelihood Of Cadmentioning

confidence: 99%

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

Saraste

Knuuti

2020

Herz

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The European Society of Cardiology (ESC) has recently published new guidelines on the diagnosis and management of chronic coronary syndromes (CCS). Due to variable symptoms, objective tests are often necessary to confirm the diagnosis, exclude alternative diagnoses, and assess the severity of underlying disease. This review provides a summary of the main diagnostic strategies listed in the guidelines for evaluation of patients suspected of having obstructive coronary artery disease (CAD). Based on data from contemporary cohorts of patients referred for diagnostic testing, the pre-test probabilities of obstructive CAD based on age, sex, and symptoms have been adjusted substantially downward compared with the previous guidelines. Further, a new concept of “clinical likelihood of CAD” was introduced accounting for the impact of various risk factors and modifiers on the pre-test probability. Noninvasive functional imaging for myocardial ischemia, coronary computed tomography angiography, or invasive coronary angiography combined with functional evaluation is recommended as the initial strategy to diagnose CAD in symptomatic patients, unless obstructive CAD can be excluded by clinical assessment alone. When available, imaging tests are recommended as noninvasive modalities instead of exercise electrocardiograms.

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Pretest probability for patients with suspected obstructive coronary artery disease: re-evaluating Diamond–Forrester for the contemporary era and clinical implications: insights from the PROMISE trial

Cited by 109 publications

References 24 publications

Clinical pre-test probability for obstructive coronary artery disease: insights from the European DISCHARGE pilot study

Clinical pre-test probability for obstructive coronary artery disease: insights from the European DISCHARGE pilot study

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

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

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