Estimation of clinical likelihood, coronary artery disease burden, and symptom relief in chronic coronary syndrome

Background The risk factor-weighted clinical likelihood (RF-CL) model is endorsed as a tool for estimating the likelihood of obstructive coronary artery disease (CAD). However, the association between RF-CL and angina relief following clinical decision-making based on coronary phenotyping remains unclear. Purpose To evaluate the association between RF-CL, CAD severity, and angina changes in patients with new-onset clinically suspected chronic coronary syndrome (CCS). Methods A total of 2,214 stable patients with new-onset chest pain and suspected CCS were included. At baseline, symptom burden was evaluated by the Seattle Angina Questionnaire (SAQ), and patients underwent coronary computed tomography angiography (CCTA). Patients with ≥50% stenosis on CCTA were further investigated with invasive coronary angiography (ICA) using fractional flow reserve (FFR) to guide decisions on revascularization. Follow-up SAQ was performed at 3 months. Patients were stratified into RF-CL categories reflecting European Society of Cardiology guideline-recommended RF-CL thresholds for test deferral/referral: ≤5%(very-low), >5-15%(low), and >15%(moderate/high). Additionally, patients were stratified by CAD severity based on the index CCTA and potential subsequent ICA with FFR and revascularization. Results At follow-up, 1,601 of 2,214 (72%) completed the SAQ. The SAQ frequency score improved in all RF-CL categories and CAD severities, except in patients with obstructive CAD at ICA who were not revascularized. In total, 630/1601 (39.7%) patients were angina-free at follow-up. In multivariate logistic regression analyses and compared to patients with RF-CL≤5%, patients with RF-CL>5-15% had higher odds of angina freedom at follow-up (OR 1.32 (CI95% 1.00–1.74), p=0.047), while patients with RF-CL>15% had similar odds (OR 0.98 (CI95% 0.71-1.37), p=0.93). Compared to patients with no CAD, patients with stenosis on CCTA without hemodynamical impairment had lower odds of angina freedom at follow-up (OR 0.50 (95% CI 0.34-0.74), p<0.001), while patients undergoing revascularization had higher odds (OR 2.78 (95%CI 1.36-0.68), p=0.005). In patients with no CAD (n=568, 35.5%)) or non-obstructive CAD (n=571, 35.7%) at CCTA, patients with RF-CL≤5% (n=496, 43.5%), RF-CL >5-15% (n=446, 39.2%), and RF-CL >15% (n=197, 17.3%) had similar rates of freedom from angina at follow-up (n=206/496, 41.5%, n=193/446, 43.3%, n=74/197, 37.6% for patients with RF-CL≤5%, >5-15%, and >15%, respectively)(fig. 2). Conclusion Low RF-CL values correctly identify patients with no CAD or non-obstructive CAD of whom 2 out of 5 patients will be angina-free at 3-month follow-up. Revascularization does improve the angina burden but was infrequently performed in patients with very-low(≤5%) RF-CL. These findings suggest that a strategy of testing deferral in patient with RF-CL≤5% can reduce the number of unnecessary CCTA as many of these patients become asymptomatic without intervention.