A risk model based on clinical and ECG stress testing variables excluded left main or left main-equivalent coronary artery disease with an AUC of 0.78 and a negative predictive value of 98.2%.
Case-Control (n=1,132)
Yes
Does a risk model using clinical and ECG stress testing variables reliably exclude left main or left main-equivalent coronary artery disease in patients with chronic coronary syndrome?
A risk model based on clinical and stress ECG variables can reliably exclude left main coronary artery disease, potentially reducing unnecessary invasive angiographies in areas with limited access to CT angiography.
Effect estimate: AUC 0.78
BACKGROUND AND AIMS: A simple diagnostic method able to reliably exclude left main (LM) coronary artery disease (CAD) or LMCAD-equivalent would expand implementation of an initial non-invasive strategy in patients with chronic coronary syndrome (CCS). This study assessed the diagnostic utility of an approach using clinical and ECG stress testing (EST) variables in excluding LMCAD/LMCAD-equivalent in CCS patients. METHODS: In a multicentre case-control study, CCS patients undergoing invasive coronary angiography (CAG) after a maximal EST were evaluated. Cases were patients with angiographic ≥ 50% LM stenosis or ≥70% stenosis of both proximal left anterior descending and proximal circumflex arteries, matched with similar patients without them (controls) in a 1:3 ratio. A risk model developed through logistic regression was internally and externally validated. RESULTS: Three hundred and thirty-five cases were matched with 797 controls. The model area under the curve (AUC) was .78. Assuming LMCAD prevalence of 5% and a misclassification cost ratio of 1:100 (ratio of cost of performing CAG in a control to cost of not performing CAG in a case), negative predictive value was 98.2%. Thus, CAG could be safely avoided in 41% of patients, missing one LMCAD/LMCAD-equivalent diagnosis for every 58 CAGs safely spared in patients without them. CONCLUSIONS: Among CCS patients, LMCAD/LMCAD-equivalent can be excluded with high negative predictive value through a model based on clinical and EST parameters, allowing initial non-invasive management of most patients able to exercise. This approach is potentially useful particularly in communities where access to computed tomography coronary angiography is limited.
“The authors concluded that among patients able to perform maximal exercise testing, combining clinical and ECG stress variables reliably excludes LMCAD, enabling an initial non-invasive OMT management strategy and potentially reducing unnecessary invasive testing, particularly where CCTA availability is limited. The authors are to be commended for addressing this topic. How translatable are these MASTER study results and score for clinical decision-making today?”
Carlo et al. (Sat,) conducted a case-control in Chronic coronary syndrome (n=1,132). Clinical and ECG stress testing risk model vs. Patients without left main or left main-equivalent coronary artery disease was evaluated on Diagnosis of left main or left main-equivalent coronary artery disease (AUC 0.78). A risk model based on clinical and ECG stress testing variables excluded left main or left main-equivalent coronary artery disease with an AUC of 0.78 and a negative predictive value of 98.2%.