Comparison of Different Investigation Strategies to Defer Cardiac Testing in Patients With Stable Chest Pain

Zhou, Jia; Li, Chunjie; Cong, Hongliang; Duan, Lixiong; Wang, Hao; Wang, Chengjian; Tan, Yahang; Liu, Yujie; Zhang, Ying; Zhou, Xiujun; Zhang, Hong; Wang, Xing; Ma, Yanhe; Yang, Junjie; Chen, Yundai; Guo, Zhigang

doi:10.1016/j.jcmg.2021.08.022

Cited by 25 publications

(51 citation statements)

References 38 publications

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“…As far as we know, this is the first comparative description of two different strategies which both included CACS-CL model: in contrast to ESC strategy, CACS-CL strategy applied CACS scan to all SCP patients. A recent study with a shorter follow-up selected CAD Consortium extended model (CCEM), which also incorporated clinical variables plus CACS, for further risk assessment in patients with borderline ESC-PTP [ 35 ]. However, the CCEM was a traditional approach to estimate pretest probability (PTP) based on ICA [ 36 ] and has been demonstrated to obviously overestimate the actual prevalence of CAD according to the calibration plots [ 14 ].…”

Section: Discussionmentioning

confidence: 99%

Comparison of risk assessment strategies incorporating coronary artery calcium score with estimation of pretest probability to defer cardiovascular testing in patients with stable chest pain

Meng

Jiang

Ren

et al. 2023

BMC Cardiovasc Disord

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Background The risk assessment of patients with stable chest pain (SCP) to defer further cardiovascular testing is crucial, but the most appropriate risk assessment strategy remains unknown. We aimed to compare current strategies to identify low risk SCP patients. Methods 5289 symptomatic patients who had undergone coronary artery calcium score (CACS) and coronary computed tomographic angiography scan were identified and followed. Pretest probability (PTP) of obstructive coronary artery disease (CAD) for every patient was estimated according to European Society of Cardiology (ESC)-PTP model and CACS-weighted clinical likelihood (CACS-CL) model, respectively. Based on the 2019 ESC guideline-determined risk assessment strategy (ESC strategy) and CACS-CL model-based risk assessment strategy (CACS-CL strategy), all patients were divided into low and high risk group, respectively. Area under receiver operating characteristic curve (AUC), integrated discrimination improvement (IDI) and net reclassification improvement (NRI) was used. Results CACS-CL model provided more robust estimation of PTP than ESC-PTP model did, with a larger AUC (0.838 versus 0.735, p < 0.0001), positive IDI (9%, p < 0.0001) and less discrepancy between observed and predicted probabilities. As a result, compared to ESC strategy which only applied CACS-CL model to patients with borderline ESC-PTP, CACS-CL strategy incorporating CACS with estimation of PTP to entire SCP patients indicated a positive NRI (19%, p < 0.0001) and a stronger association to major adverse cardiovascular events, with hazard ratios: 3.97 (95% confidence intervals: 2.75–5.72) versus 5.11 (95% confidence intervals: 3.40–7.69). Conclusion The additional use of CACS for all SCP patients in CACS-CL strategy improved the risk assessment of SCP patients to identify individuals at low risk.

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Section: Discussionmentioning

confidence: 99%

Comparison of risk assessment strategies incorporating coronary artery calcium score with estimation of pretest probability to defer cardiovascular testing in patients with stable chest pain

Meng

Jiang

Ren

et al. 2023

BMC Cardiovasc Disord

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“… 6 The simple coronary artery calcium score clinical likelihood graphical tool has showed superiority to both ESC‐PTP and use of coronary calcium alone, therefore further improving the classification and increasing the number of patients with very low PTP. 6 , 13 Part of these data was also adopted into the 2021 AHA/ACC guidelines on chest pain. 7 However, in which patients coronary artery calcium score testing is most beneficial for clinical decision‐making is still unknown.…”

Section: Discussionmentioning

confidence: 99%

“…Furthermore, the RF‐CL model showed consistently high performance when externally validated in 4403 American patients included in the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) and 4207 patients included at the Tianjin Chest Hospital, China. 6 , 13 , 14 …”

Section: Limitationsmentioning

confidence: 99%

Performance of the American Heart Association/American College of Cardiology Guideline‐Recommended Pretest Probability Model for the Diagnosis of Obstructive Coronary Artery Disease

Winther

Murphy

Schmidt

et al. 2022

JAHA

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Background Substantial differences exist between different guideline‐recommended pretest probability (PTP) models for the detection of obstructive coronary artery disease (CAD). This study was performed to study the performance of the 2021 American Heart Association/American College of Cardiology (AHA/ACC) guideline‐recommended PTP (AHA/ACC‐PTP) model in assessing the likelihood of obstructive CAD compared with previously proposed models. Methods and Results Symptomatic patients (N=50 561) referred for coronary computed tomography angiography were included. The reference standard was invasive coronary angiography with optional fractional flow reserve measurements. The AHA/ACC‐PTP values based on sex and age were calculated and compared with the 2019 European Society of Cardiology guideline PTP values based on sex, age, and symptoms as well as the risk factor–weighted clinical likelihood values based on sex, age, symptoms, and risk factors. The AHA/ACC‐PTP maximum values overestimated by a factor of 2.6 the actual prevalence of CAD. Compared with the AHA/ACC‐PTP model (area under the receiver‐operating curve, 71.5 [95% CI, 70.7–72.2]), inclusion of typicality of symptoms in the European Society of Cardiology guideline PTP improved discrimination of CAD (area under the receiver‐operating curve, 75.5 [95% CI, 74.7–76.3]). Inclusion of both symptoms and risk factors in the risk factor–weighted clinical likelihood model further improved discrimination (area under the receiver‐operating curve, 77.7 [95% CI, 77.0–78.5]). The proportion of patients classified as very low PTP was lower using the AHA/ACC‐PTP (5%) compared with the European Society of Cardiology guideline PTP (19%) and the risk factor–weighted clinical likelihood (49%) models. Conclusions The new AHA/ACC‐PTP model overestimates the prevalence of obstructive CAD substantially if type of symptoms and risk factors are not taken into account. Inclusion of both symptoms and risk factors improves model performance and identifies more patients with very low likelihood of CAD in whom further testing can be deferred.

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“…26 Finally, CAC scoring represents a valuable additional risk factor to enhance the prediction of obstructive CAD. 27 More recently, data from Hughes-Austin et al 28 claim that CAC scores obtained from standard 6 mm chest CTs not only correlate strongly with 3 mm ECG-gated CTs but also are useful in predicting adverse events. Simply stated, any chest CT performed for any other clinical indication is still useful in providing CVD risk information.…”

Section: Coronary Computed Tomography Angiography and Coronary Artery...mentioning

confidence: 99%

Improving diagnostic assessments in the ever-changing landscape of atherosclerosis

López‐Candales

Sawalha

2023

Journal of Cardiovascular Medicine

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As our understanding of atherosclerotic vascular injury continues to evolve, so should our diagnostic approaches. Emerging data have recently challenged our basic understanding in linking ischemia to its adverse outcomes as well as the need for invasive testing for both diagnosis and treatment. The advent of coronary computed tomography in providing improved visualization of coronary arteries has led to the identification of both subclinical atherosclerosis and high-risk coronary lesions. Recognition of asymptomatic coronary artery disease (CAD) with objective localization of subclinical coronary atherosclerosis improves atherosclerotic cardiovascular risk assessment and allows healthcare providers to take effective primary prevention measures. Therefore, reshaping the diagnostic landscape in proposing new testing modalities would be highly dependent on local resource availability and the reading expertise of each clinical practice and medical institution. The main objective of this Review is to propose a potentially new diagnostic approach of simply using noninvasive stress testing or coronary angiography in the routine assessment of CAD.

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Comparison of Different Investigation Strategies to Defer Cardiac Testing in Patients With Stable Chest Pain

Cited by 25 publications

References 38 publications

Comparison of risk assessment strategies incorporating coronary artery calcium score with estimation of pretest probability to defer cardiovascular testing in patients with stable chest pain

Comparison of risk assessment strategies incorporating coronary artery calcium score with estimation of pretest probability to defer cardiovascular testing in patients with stable chest pain

Performance of the American Heart Association/American College of Cardiology Guideline‐Recommended Pretest Probability Model for the Diagnosis of Obstructive Coronary Artery Disease

Improving diagnostic assessments in the ever-changing landscape of atherosclerosis

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