Clinical pre-test probability for obstructive coronary artery disease: insights from the European DISCHARGE pilot study
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COMPUTED TOMOGRAPHY
Clinical pre-test probability for obstructive coronary artery disease: insights from the European DISCHARGE pilot study Sarah Feger 1 & Paolo Ibes 1 & Adriane E. Napp 1 & Alexander Lembcke 1 & Michael Laule 1 & Henryk Dreger 1 & Björn Bokelmann 1 & Gershan K. Davis 2,3 & Giles Roditi 4 & Ignacio Diez 5 & Stephen Schröder 6 & Fabian Plank 7 & Pal Maurovich-Horvat 8 & Radosav Vidakovic 9 & Josef Veselka 10 & Malgorzata Ilnicka-Suckiel 11 & Andrejs Erglis 12 & Teodora Benedek 13 & José Rodriguez-Palomares 14,15 & Luca Saba 16 & Klaus F. Kofoed 17 & Matthias Gutberlet 18 & Filip Ađić 19 & Mikko Pietilä 20 & Rita Faria 21 & Audrone Vaitiekiene 22 & Jonathan D. Dodd 23 & Patrick Donnelly 24 & Marco Francone 25 & Cezary Kepka 26 & Balazs Ruzsics 27 & Jacqueline Müller-Nordhorn 28 & Peter Schlattmann 29 & Marc Dewey 1,30,31 Received: 26 November 2019 / Revised: 3 June 2020 / Accepted: 10 August 2020 # The Author(s) 2020
Abstract 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 st
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