Comparison of International Guidelines for Assessment of Suspected Stable Angina

Abstract

ObjectivesThis study sought to compare the performance of major guidelines for the assessment of stable chest pain including risk-based (American College of Cardiology/American Heart Association and European Society of Cardiology) and symptom-focused (National Institute for Health and Care Excellence) strategies.BackgroundAlthough noninvasive testing is not recommended in low-risk individuals with stable chest pain, guidelines recommend differing approaches to defining low-risk patients.MethodsPatient-level data were obtained from the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) and SCOT-HEART (Scottish Computed Tomography of the Heart) trials. Pre-test probability was determined and patients dichotomized into low-risk and intermediate-high–risk groups according to each guideline’s definitions. The primary endpoint was obstructive coronary artery disease on coronary computed tomography angiography. Secondary endpoints were coronary revascularization at 90 days and cardiovascular death or nonfatal myocardial infarction up to 3 years.ResultsIn total, 13,773 patients were included of whom 6,160 had coronary computed tomography angiography. The proportions of patients identified as low risk by the American College of Cardiology/American Heart Association, European Society of Cardiology, and National Institute for Health and Care Excellence guidelines, respectively, were 2.5%, 2.5%, and 10.0% within PROMISE, and 14.0%, 19.8%, and 38.4% within SCOT-HEART. All guidelines identified lower rates of obstructive coronary artery disease in low- versus intermediate-high–risk patients with a negative predictive value of ≥0.90. Compared with low-risk groups, all intermediate-high–risk groups had greater risks of coronary revascularization (odds ratio [OR]: 2.2 to 24.1) and clinical outcomes (OR: 1.84 to 5.8).ConclusionsCompared with risk-based guidelines, symptom-focused assessment identifies a larger group of low-risk chest pain patients potentially deriving limited benefit from noninvasive testing. (Scottish Computed Tomography of the Heart Trial [SCOT-HEART]; NCT01149590; Prospective Multicenter Imaging Study for Evaluation of Chest Pain [PROMISE]; NCT01174550)

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

“…It has been established across several cohort studies that the previous ESC Diamond and Forrester pre-test probabilities overestimated the prevalence of disease, with a previous collaboration between SCOT-HEART and PROMISE investigators demonstrating more identification of low-risk patients with the symptom-based National Institute of Health and Care Excellence guidelines. 11 Indeed, although not the focus of this analysis, the Diamond and Forrester estimates exceeded the observed disease prevalence in nearly all groups in our cohort ( Table 3 ). This led to changes in the most recent iteration of the ESC guidelines 5 , 12 which pooled three separate cohorts for this update.…”

Place of clinical evaluation in the identification of obstructive coronary arteries lesions in patients with stable coronary artery disease: Part II

“…Понятно, что правильное выделение именно группы низкого риска имеет важное практическое значение, поскольку таких больных предлагается больше не обследовать в любом из диагностических алгоритмов. Adamson PD, et al [12] решили проверить на независимых выборках способность наиболее распространенных шкал оценки ПТВ в выявлении такой категории больных. Они проанализировали когорту из 6160 пациентов из исследований PROMISE и SCOT-HEART, которым было проведена МСКТ ангиография КА, и выделяли группу низкого риска по рекомендациям АСС/АНА [1], ЕОК [2] и NICE (2016) [13].…”

“…Несколько хуже были значения данного показателя, полученного при использовании рекомендаций NICE: только 0,914 и 0,905, соответственно. Также по сравнению с выявленной группой низкого риска в группе промежуточно-высокого риска отмечен больший риск коронарной реваскуля-ризации (отношение рисков (ОР) 2,2-24,1) и развития конечных точек (ОР 1,84-5,8) [12].…”

“…Также при использовании алгоритма NICE-2016 по сравнению с рекомендациями ESC и АНА/АСС в 2-4 раза увеличивается число больных с низким риском наличия ИБС. Но в этой расширенной группе низкого риска при проспективном наблюдении чаще наблюдались сердечно-сосудистые события и негативное предсказательное значение оказалось при таком подходе наименьшим [12]. С другой стороны, было показано, что проведение МСКТ-АГ не повлияло бы на частоту последующего проведения инвазивной КАГ (p=0,481) у больных с возможной стенокардией, и даже повысило бы ее у пациентов с неангинальной болью (ОР 1,82; p=0,014).…”

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

“…However, currently there are no randomized controlled trials that include evaluation of outcomes with a “no-test” strategy. Therefore, performing diagnostic testing also in patients with a new PTP of 5–15% more closely reflects current clinical practice and may be considered appropriate, particularly if symptoms are limiting and require clarification [ 1 , 12 ]. Patient preference, local resources and availability of tests, clinical judgment, and appropriate patient information remain important for the decision to proceed with noninvasive diagnostic testing in an individual patient when the PTP is 5–15%, and the higher likelihood of a false-positive test must be considered [ 1 ].…”