Predicting Coronary Artery Disease in Primary Care: Development and Validation of a Diagnostic Risk Score for Major Ethnic Groups in Southeast Asia

Abstract

BACKGROUND: Coronary artery disease (CAD) risk prediction tools are useful decision supports. Their clinical impact has not been evaluated amongst Asians in primary care. OBJECTIVE: We aimed to develop and validate a diagnostic prediction model for CAD in Southeast Asians by comparing it against three existing tools. DESIGN: We prospectively recruited patients presenting to primary care for chest pain between July 2013 and December 2016. CAD was diagnosed at tertiary institution and adjudicated. A logistic regression model was built, with validation by resampling. We validated the Duke Clinical Score (DCS), CAD Consortium Score (CCS), and Marburg Heart Score (MHS). MAIN MEASURES: Discrimination and calibration quantify model performance, while net reclassification improvement and net benefit provide clinical insights. KEY RESULTS: CAD prevalence was 9.5% (158 of 1658 patients). Our model included age, gender, type 2 diabetes mellitus, hypertension, smoking, chest pain type, neck radiation, Q waves, and ST-T changes. The C-statistic was 0.808 (95% CI 0.776-0.840) and 0.815 (95% CI 0.782-0.847), for model without and with ECG respectively. C-statistics for DCS, CCS-basic, CCS-clinical, and MHS were 0.795 (95% CI 0.759-0.831), 0.756 (95% CI 0.717-0.794), 0.787 (95% CI 0.752-0.823), and 0.661 (95% CI 0.621-0.701). Our model (with ECG) correctly reclassified 100% of patients when compared with DCS and CCS-clinical respectively. At 5% threshold probability, the net benefit for our model (with ECG) was 0.063. The net benefit for DCS, CCS-basic, and CCS-clinical was 0.056, 0.060, and 0.065. CONCLUSIONS: PRECISE (Predictive Risk scorE for CAD In Southeast Asians with chEst pain) performs well and demonstrates utility as a clinical decision support for diagnosing CAD among Southeast Asians.

Evaluation of the Marburg Heart Score and INTERCHEST score compared to current telephone triage for chest pain in out-of-hours primary care

“…Overall, best results were obtained when applying a threshold of 3 points, and repeated validation showed a discriminative ability ranging from 0.84 to 0.90, with good sensitivity (87–91%) and specificity (61–81%) [ 8 , 9 , 16 ]. Additional external validation of the MHS among patients in Southeast Asia resulted in a less favourable discriminative ability of 0.66 (95% CI: 0.62–0.70) [ 17 ]. The MHS was also tested for its ability to rule out ACS among a selected patient population referred for immediate cardiac evaluation because an ACS was suspected [ 18 ].…”