Validation and update of the minimal risk tool in patients suspected of chronic coronary syndrome
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ORIGINAL PAPER
Validation and update of the minimal risk tool in patients suspected of chronic coronary syndrome Laust Dupont Rasmussen1 · Louise Nissen1 · Jelmer Westra2 · Lars Lyhne Knudsen1 · Lene Helleskov Madsen1 · Niels Ramsing Holm2 · Evald Høj Christiansen2 · Hans Erik Bøtker2 · Morten Bøttcher1 · Simon Winther1 Received: 27 May 2020 / Accepted: 24 August 2020 © Springer Nature B.V. 2020
Abstract Risk stratification in patients with suspected coronary artery disease (CAD) is important. Recently, the minimal-risk-tool (MRT) was developed to identify individuals with low CAD risk despite symptoms in order to avoid unnecessary testing. We aimed to validate and update the MRT-model in a contemporary cohort. The Dan-NICAD trial cohort, consisting of 1675 consecutive patients referred for coronary computed tomography angiography (CTA), was used to calculate the MRT-score based on the published fitted variable coefficients from the PROMISE and SCOT-HEART trials. Minimal risk was defined as zero calcium score, no coronary atherosclerosis at coronary CTA, and no cardiovascular events in the follow-up period. We tested an updated MRT-model by pooling the fitted variable coefficients from all three trials. A total of 1544 patients fulfilling the inclusion criteria were followed for 3.1 [2.7–3.4] years. In 710 (46%) patients, the criteria for minimal risk were fulfilled. Despite substantial coefficient variation, the MRTs based on the PROMISE, the SCOT-HEART and the updated MRT variables showed similar moderate to high discriminative performance for minimal risk estimation. Although all three models tended to underestimate minimal risk, the updated MRT had the best performance. Using a 75% minimal risk cutoff, the updated MRT showed a sensitivity of 11.6% (95% CI 9.3–14.2%) and specificity of 99.3% (95% CI 98.6–99.8%). An updated MRT model based on three large studies increased calibration compared to the existing MRT models, whereas discrimination was similar despite substantial coefficient variation. The updated MRT might supplement currently recommended pre-test probability models. Keywords Coronary artery disease · Pre-test probability · Minimal risk Abbreviations PTP Pre-test probability CAD Coronary artery disease Laust Dupont Rasmussen, Louise Nissen, Jelmer Westra, Lars Lyhne Knudsen, Lene Helleskov Madsen, Niels Ramsing Holm, Evald Høj Christiansen, Hans Erik Bøtker, Morten Bøttcher, and Simon Winther authors takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation. Electronic supplementary material The online version of this article (https://doi.org/10.1007/s10554-020-01982-7) contains supplementary material, which is available to authorized users.
ESC European Society of Cardiology PROMISE Prospective Multicenter Imaging Study for Evaluation of Chest Pain SCOT-HEART Scottish COmputed Tomography of the HEART trial MRT Minimal risk tool Dan-NICAD Danish study of Non-Invasive testing in Coronary Artery Disease CTA
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