Identification of patients with stable chest pain deriving minimal value from coronary computed tomography angiography: An external validation of the PROMISE minimal-risk tool

Adamson, Philip D; Fordyce, Christopher B.; McAllister, David A; Udelson, James E.; Douglas, Pamela S.; Newby, David E.

doi:10.1016/j.ijcard.2017.09.033

Cited by 29 publications

(22 citation statements)

References 20 publications

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“…In both trials, the use of a symptom-focused strategy endorsed by NICE, in contrast with a Bayesian–risk based approach endorsed by ACC/AHA and ESC, resulted in a 3- to 4-fold increase in the number of patients for whom no further investigation for the presence of CAD is recommended. This is reassuring given concerns raised recently that the updated NICE guidance would lead to an increase in indiscriminate diagnostic testing (19) , as well as strategies being considered to defer testing in those patients with very low risk 20 , 21 . Furthermore, the group designated by NICE for no testing (nonanginal symptoms) demonstrated <10% prevalence of coronary obstruction across both trial cohorts, below the threshold adjudged to reflect low risk in both the ACC/AHA and ESC guidelines.…”

Section: Discussionmentioning

confidence: 90%

Comparison of International Guidelines for Assessment of Suspected Stable Angina

Adamson

Newby

Hill

et al. 2018

JACC: Cardiovascular Imaging

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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)

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Section: Discussionmentioning

confidence: 90%

Comparison of International Guidelines for Assessment of Suspected Stable Angina

Adamson

Newby

Hill

et al. 2018

JACC: Cardiovascular Imaging

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“…We believe that this likely to reflect differences in the populations studied, with SCOT-HEART including a broader risk spectrum of patients as we have reported previously. 14 …”

Section: Discussionmentioning

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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“…Fourth, a new model, the PROMISE minimal-risk tool, was developed recently to identify patients with stable chest pain at very low risk of CAD and clinical events 36. This risk score provided a novel strategy to identify patients in whom noninvasive testing might be deferred safely and outperformed existing PTP models 37. Thus, more external validation investigations are needed in the future to determine whether the application of the PROMISE minimal-risk tool can reduce unnecessary testing safely and effectively, especially for women.…”

Section: Discussionmentioning

confidence: 99%

Impact of sex-specific differences in calculating the pretest probability of obstructive coronary artery disease in symptomatic patients

Zhang¹,

Liu²,

Zhang

et al. 2019

Coronary Artery Disease

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Objectives Little is known about the impact of sex-specific differences in calculating the pretest probability (PTP) of obstructive coronary artery disease. We sought to determine whether the calculation of PTP differ by sex in symptomatic patients referred to coronary computed tomographic angiography (CCTA). Patients and methods The characteristics of 5777 men and women who underwent CCTA were compared. For each patient, PTP was calculated according to the updated Diamond–Forrester method (UDFM) and the Duke clinical score (DCS), respectively. Follow-up clinical data were also recorded. Area under the receiver operating characteristic curve, integrated discrimination improvement, net reclassification improvement, and the Hosmer–Lemeshow goodness-of-fit statistic were used to assess the models’ performance. Results The area under the receiver operating characteristic curve of UDFM and DCS showed little difference in men (0.782 vs. 0.785, P =0.4708) and women (0.668 vs. 0.654, P =0.1255), and calibration of neither model was satisfactory. Compared with UDFM, DCS showed positive integrated discrimination improvement (10% in men, P <0.0001, and 8% in women, P <0.0001, respectively), net reclassification improvement (12.17% in men, P <0.0001, and 27.19% in women, P <0.0001, respectively), and obviously reduced unnecessary noninvasive testing for women with negative CCTA. Conclusion Although the performance of neither model was favorable, DCS offered a more accurate calculation of PTP than UDFM and application of DCS instead of UDFM would result in a significant decrease in inappropriate testing, especially in women.

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Identification of patients with stable chest pain deriving minimal value from coronary computed tomography angiography: An external validation of the PROMISE minimal-risk tool

Cited by 29 publications

References 20 publications

Comparison of International Guidelines for Assessment of Suspected Stable Angina

Comparison of International Guidelines for Assessment of Suspected Stable Angina

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

Impact of sex-specific differences in calculating the pretest probability of obstructive coronary artery disease in symptomatic patients

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