Prediction of obstructive coronary artery disease and prognosis in patients with suspected stable angina
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Prediction of obstructive coronary artery disease and prognosis in patients with suspected stable angina. / Reeh, Jacob; Therming, Christina Bachmann; Heitmann, Merete; Højberg, Søren; Sørum, Charlotte; Bech, Jan; Husum, Dorte; Dominguez, Helena; Sehestedt, Thomas; Hermann, Thomas; Hansen, Kim Wadt; Simonsen, Lene; Galatius, Søren; Prescott, Eva.
In: European Heart Journal, Vol. 18, No. 7, 2019, p. 1426–1435.Research output: Contribution to journal › Journal article › Research › peer-review
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TY - JOUR
T1 - Prediction of obstructive coronary artery disease and prognosis in patients with suspected stable angina
AU - Reeh, Jacob
AU - Therming, Christina Bachmann
AU - Heitmann, Merete
AU - Højberg, Søren
AU - Sørum, Charlotte
AU - Bech, Jan
AU - Husum, Dorte
AU - Dominguez, Helena
AU - Sehestedt, Thomas
AU - Hermann, Thomas
AU - Hansen, Kim Wadt
AU - Simonsen, Lene
AU - Galatius, Søren
AU - Prescott, Eva
PY - 2019
Y1 - 2019
N2 - Aims: We hypothesized that the modified Diamond-Forrester (D-F) prediction model overestimates probability of coronary artery disease (CAD). The aim of this study was to update the prediction model based on pre-test information and assess the model's performance in predicting prognosis in an unselected, contemporary population suspected of angina.Methods and results: We included 3903 consecutive patients free of CAD and heart failure and suspected of angina, who were referred to a single centre for assessment in 2012-15. Obstructive CAD was defined from invasive angiography as lesion requiring revascularization, >70% stenosis or fractional flow reserve <0.8. Patients were followed (mean follow-up 33 months) for myocardial infarction, unstable angina, heart failure, stroke, and death. The updated D-F prediction model overestimated probability considerably: mean pre-test probability was 31.4%, while only 274 (7%) were diagnosed with obstructive CAD. A basic prediction model with age, gender, and symptoms demonstrated good discrimination with C-statistics of 0.86 (95% CI 0.84-0.88), while a clinical prediction model adding diabetes, family history, and dyslipidaemia slightly improved the C-statistic to 0.88 (0.86-0.90) (P for difference between models <0.0001). Quartiles of probability of CAD from the clinical prediction model provided good diagnostic and prognostic stratification: in the lowest quartiles there were no cases of obstructive CAD and cumulative risk of the composite endpoint was less than 3% at 2 years.Conclusion: The pre-test probability model recommended in current ESC guidelines substantially overestimates likelihood of CAD when applied to a contemporary, unselected, all-comer population. We provide an updated prediction model that identifies subgroups with low likelihood of obstructive CAD and good prognosis in which non-invasive testing may safely be deferred.
AB - Aims: We hypothesized that the modified Diamond-Forrester (D-F) prediction model overestimates probability of coronary artery disease (CAD). The aim of this study was to update the prediction model based on pre-test information and assess the model's performance in predicting prognosis in an unselected, contemporary population suspected of angina.Methods and results: We included 3903 consecutive patients free of CAD and heart failure and suspected of angina, who were referred to a single centre for assessment in 2012-15. Obstructive CAD was defined from invasive angiography as lesion requiring revascularization, >70% stenosis or fractional flow reserve <0.8. Patients were followed (mean follow-up 33 months) for myocardial infarction, unstable angina, heart failure, stroke, and death. The updated D-F prediction model overestimated probability considerably: mean pre-test probability was 31.4%, while only 274 (7%) were diagnosed with obstructive CAD. A basic prediction model with age, gender, and symptoms demonstrated good discrimination with C-statistics of 0.86 (95% CI 0.84-0.88), while a clinical prediction model adding diabetes, family history, and dyslipidaemia slightly improved the C-statistic to 0.88 (0.86-0.90) (P for difference between models <0.0001). Quartiles of probability of CAD from the clinical prediction model provided good diagnostic and prognostic stratification: in the lowest quartiles there were no cases of obstructive CAD and cumulative risk of the composite endpoint was less than 3% at 2 years.Conclusion: The pre-test probability model recommended in current ESC guidelines substantially overestimates likelihood of CAD when applied to a contemporary, unselected, all-comer population. We provide an updated prediction model that identifies subgroups with low likelihood of obstructive CAD and good prognosis in which non-invasive testing may safely be deferred.
U2 - 10.1093/eurheartj/ehy806
DO - 10.1093/eurheartj/ehy806
M3 - Journal article
C2 - 30561616
VL - 18
SP - 1426
EP - 1435
JO - European Heart Journal
JF - European Heart Journal
SN - 0195-668X
IS - 7
ER -
ID: 217702760