September 9, 2020European RadiologyOpen Access

Clinical pre-test probability for obstructive coronary artery disease: insights from the European DISCHARGE pilot study

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Why the study?

To test the accuracy of clinical pre-test probability for the prediction of obstructive coronary artery disease in a pan-European setting.

Does the updated Diamond-Forrester (D+F) model from 2011 improve the accuracy of pre-test probability prediction for obstructive coronary artery disease compared to the initial D+F model from 1979 in patients with stable chest pain?

Structured PICO

Population

1,440 patients with suspected CAD and stable chest pain clinically referred for invasive coronary angiography (ICA) or computed tomography (CT), mean age 64 (ICA) and 59 (CT), 45% female, multinational (16 European countries). Key inclusion: at least 30 years of age, routinely scheduled for suspected CAD. Key exclusion: known CAD including prior MI or revascularization, not in sinus rhythm, pregnant, or requiring haemodialysis.

Intervention

Pre-test probability (PTP) calculation using the updated Diamond-Forrester (D+F) prediction model from 2011

Comparator

Pre-test probability (PTP) calculation using the initial Diamond-Forrester (D+F) prediction model from 1979

Outcome

Accuracy of clinical pre-test probability (PTP) for prediction of obstructive coronary artery disease (CAD), defined by at least one 50% diameter coronary stenosis by both CT and ICAsurrogate

Both the initial and updated Diamond-Forrester models significantly overestimate the prevalence of obstructive CAD in patients with stable chest pain, though the updated 2011 model provides slightly better discriminative accuracy.

Implication

Both models overestimate obstructive CAD; updated version's modest discrimination gain leaves open need for recalibration in contemporary cohorts.

Abstract

OBJECTIVES: To test the accuracy of clinical pre-test probability (PTP) for prediction of obstructive coronary artery disease (CAD) in a pan-European setting. METHODS: Patients with suspected CAD and stable chest pain who were clinically referred for invasive coronary angiography (ICA) or computed tomography (CT) were included by clinical sites participating in the pilot study of the European multi-centre DISCHARGE trial. PTP of CAD was determined using the Diamond-Forrester (D+F) prediction model initially introduced in 1979 and the updated D+F model from 2011. Obstructive coronary artery disease (CAD) was defined by one at least 50% diameter coronary stenosis by both CT and ICA. RESULTS: In total, 1440 patients (654 female, 786 male) were included at 25 clinical sites from May 2014 until July 2017. Of these patients, 725 underwent CT, while 715 underwent ICA. Both prediction models overestimated the prevalence of obstructive CAD (31.7%, 456 of 1440 patients, PTP: initial D+F 58.9% (28.1-90.6%), updated D+F 47.3% (34.2-59.9%), both p < 0.001), but overestimation of disease prevalence was higher for the initial D+F (p < 0.001). The discriminative ability was higher for the updated D+F 2011 (AUC of 0.73 95% confidence interval [CI] 0.70-0.76 versus AUC of 0.70 CI 0.67-0.73 for the initial D+F; p < 0.001; odds ratio (or) 1.55 CI 1.29-1.86, net reclassification index 0.11 CI 0.05-0.16, p < 0.001). CONCLUSIONS: Clinical PTP calculation using the initial and updated D+F prediction models relevantly overestimates the actual prevalence of obstructive CAD in patients with stable chest pain clinically referred for ICA and CT suggesting that further refinements to improve clinical decision-making are needed. TRIAL REGISTRATION: https://www.clinicaltrials.gov/ct2/show/NCT02400229 KEY POINTS: • Clinical pre-test probability calculation using the initial and updated D+F model overestimates the prevalence of obstructive CAD identified by ICA and CT. • Overestimation of disease prevalence is higher for the initial D+F compared with the updated D+F. • Diagnostic accuracy of PTP assessment varies strongly between different clinical sites throughout Europe.