Overestimation of pretest probability of coronary artery disease by Duke clinical score in patients undergoing coronary CT angiography in a Japanese population

Shim

Journal of Women's Health

et al. 2016

Section: Discussionsupporting

confidence: 66%

Utility of Pretest Probability and Exercise Treadmill Test in Korean Women with Suspected Coronary Artery Disease

Shim

Journal of Women's Health

et al. 2016

“…In this specific population of patients referred to ICA, DCS and CAD1 scores overestimated the prevalence of obstructive CAD. This was previously demonstrated for DCS score in patients referred to CCTA . It may be related to a contemporary lower prevalence of CAD as compared with the historic cohorts that served as the base for the development of that model .…”

Section: Discussionmentioning

confidence: 63%

“…8,9 Although DCS seems to improve prediction of CAD in patients referred to coronary computed tomographic angiography (CCTA) as compared with DF, 10 it still appears to overestimate PTP. 11,12 Recently, CAD Consortium 2 (CAD2), which also includes modifiable cardiovascular risk factors, was created and demonstrated accuracy for the prediction of CAD in low-risk populations. 11 The accuracy of this method in patients referred to ICA is not known.…”

Section: Introductionmentioning

confidence: 99%

Comparison of Coronary Artery Disease Consortium 1 and 2 Scores and Duke Clinical Score to Predict Obstructive Coronary Disease by Invasive Coronary Angiography

Almeida

Fonseca

Dias

et al. 2016

Clinical Cardiology

Background The first step in evaluating a patient with suspected stable coronary artery disease (CAD) is the determination of the pretest probability. The European Society of Cardiology guidelines recommend the use of the CAD Consortium 1 score (CAD1), which contrary to CAD Consortium 2 (CAD2) score and Duke Clinical Score (DCS), does not include modifiable cardiovascular risk factors. Hypothesis Using scores that include modifiable risk factors (DCS and CAD2) enhances prediction of CAD. Methods We retrospectively included all patients referred to invasive coronary angiography for suspected CAD from January/2008–December/2012 (N = 2234). Pretest probability was calculated using 3 models (CAD1, DCS, and CAD2), and they were compared using the net reclassification improvement. Results Mean patient age was 63.7 years, 67.5% were male, and the majority (66.9%) had typical angina. Coronary artery disease was diagnosed in 58.5%, and the area under the curve was 0.685 for DCS, 0.664 for CAD1, and 0.683 for CAD2, with a statistically significant difference between CAD1 and the others (P < 0.001). The net reclassification improvement was 20% for DCS, related to adequate reclassification of 32% of patients with CAD to a higher risk category, and 5% for CAD2, at the cost of adequate reclassification of 34% of patients without CAD to a lower risk category. Conclusions Prediction of CAD using scores that include modifiable cardiovascular risk factors seems to improve accuracy. Our results suggest that, in high‐prevalence populations, DCS may better identify patients at higher risk and CAD2 those at lower risk for CAD.

Circ: Cardiovascular Quality and Outcomes

“…3-5 However, there is evidence both that these models may overestimate risk [6][7][8] and that clinician use of stratification tools remains suboptimal. 9,10 In light of these challenges, there is widespread interest in identifying suitable biomarkers that may improve diagnostic accuracy in patients with suspected stable CAD.…”

mentioning

confidence: 99%

“…2 Several national and international bodies have proposed standardized pathways that use risk models to estimate the pretest probability (PTP) of obstructive CAD and guide decision making with regards to appropriate use of investigations. [3][4][5] However, there is evidence both that these models may overestimate risk [6][7][8] and that clinician use of stratification tools remains suboptimal. 9,10 In light of these challenges, there is widespread interest in identifying suitable biomarkers that may improve diagnostic accuracy in patients with suspected stable CAD.…”

mentioning

confidence: 99%

High-Sensitivity Cardiac Troponin I and the Diagnosis of Coronary Artery Disease in Patients With Suspected Angina Pectoris

Adamson

Hunter

Madsen

et al. 2018

BACKGROUND:We determined whether high-sensitivity cardiac troponin I can improve the estimation of the pretest probability for obstructive coronary artery disease (CAD) in patients with suspected stable angina. METHODS AND RESULTS:In a prespecified substudy of the SCOT-HEART trial (Scottish Computed Tomography of the Heart), plasma cardiac troponin was measured using a high-sensitivity single-molecule counting assay in 943 adults with suspected stable angina who had undergone coronary computed tomographic angiography. Rates of obstructive CAD were compared with the pretest probability determined by the CAD Consortium risk model with and without cardiac troponin concentrations. External validation was undertaken in an independent study population from Denmark comprising 487 patients with suspected stable angina. Higher cardiac troponin concentrations were associated with obstructive CAD with a 5-fold increase across quintiles (9%-48%; P<0.001) independent of known cardiovascular risk factors (odds ratio, 1.35; 95% confidence interval, 1.25-1.46 per doubling of troponin). Cardiac troponin concentrations improved the discrimination and calibration of the CAD Consortium model for identifying obstructive CAD (C statistic, 0.788-0.800; P=0.004; χ 2 =16.8 [P=0.032] to 14.3 [P=0.074]). The updated model also improved classification of the American College of Cardiology/American Heart Association pretest probability risk categories (net reclassification improvement, 0.062; 95% confidence interval, 0.035-0.089). The revised model achieved similar improvements in discrimination and calibration when applied in the external validation cohort. CONCLUSIONS:High-sensitivity cardiac troponin I concentration is an independent predictor of obstructive CAD in patients with suspected stable angina. Use of this test may improve the selection of patients for further investigation and treatment. CLINICAL TRIAL REGISTRATION: Presentations with suspected stable angina are common, yet determining an accurate diagnosis is frequently challenging. Patients and clinicians alike are understandably keen to identify the cause of the symptoms in order that these can be treated and hopefully ameliorated. Of equal importance is the concern that these symptoms may reflect prognostically significant atherosclerotic disease with the associated risk of future cardiovascular events. These concerns are appropriate given that 1 in 6 patients will experience coronary death or nonfatal acute coronary syndrome in the 3 years after a diagnosis of stable angina.1 Importantly, this risk remains substantial even in those patients with symptoms deemed noncardiac in origin.1 Consequently, despite the central role of the clinical history and cardiovascular risk factor ascertainment in the assessment process, supplementary investigations are frequently required to provide additional certainty related to the presence or absence of obstructive coronary artery disease (CAD). 2Several national and international bodies have proposed standardized pathways that use risk m...