Key result
Updated 2024 ESC guidelines safely improve imaging deferral with ~6% net reclassification over 2019 strategy.
Why the study?
The 2019 and 2024 ESC guidelines provide different risk assessment strategies for determining the need for advanced cardiovascular imaging in patients with stable chest pain, but their comparative safety and effectiveness were unclear.
Does the 2024 ESC risk assessment strategy improve risk stratification and reduce unnecessary imaging compared to the 2019 ESC strategy in patients with stable chest pain?
Cohort (n=17,612)
Does the 2024 ESC risk assessment strategy improve risk stratification and reduce unnecessary imaging compared to the 2019 ESC strategy in patients with stable chest pain?
Effect estimate: NRI 6.11%
Absolute Event Rate: 3.9% vs 3.9%
Number Needed to Treat: 17
p-value: p=<0.001
The 2024 ESC risk assessment strategy for stable chest pain safely defers more patients from unnecessary cardiovascular imaging compared to the 2019 strategy, with a positive net reclassification improvement.
Supports increased deferral of imaging with 2024 ESC strategy in stable chest pain; extends 2019 guidelines but leaves open prospective validation.
Background: The European Society of Cardiology issued guidelines in 2019 and 2024 to help clinicians determine whether patients with stable chest pain (SCP) require advanced cardiovascular imaging testing (CIT). This study aimed to compare the safety and effectiveness of these evaluation strategies. Methods: A total of 17,612 symptomatic patients referred for coronary computed tomography angiography (CCTA) were included and followed over time. Each patient was classified into a deferral or referral group according to the 2019 and 2024 strategies, respectively. Obstructive coronary artery disease (CAD) was primarily defined as a lesion with ≥50% diameter stenosis on CCTA. Associations between major adverse cardiovascular events (MACEs) and the deferral and referral groups were evaluated using hazard ratios (HRs). Net reclassification improvement (NRI) and the number needed to test (NNT) to prevent unnecessary CIT were used to compare the two strategies. Results: Under the 2019 and 2024 strategies, 40% and 46% of patients, respectively, were categorized into deferral groups. These groups demonstrated a low prevalence of obstructive CAD (9.8% and 9.4%) and MACE (3.9% and 3.9%), suggesting that only limited intensive clinical follow-up was needed. Compared with the 2019 strategy, the 2024 strategy revealed a stronger association with MACEs (HR: 3.64 vs. 3.28) and a positive NRI (6.11%; p < 0.001), resulting in an NNT of 17. Conclusions: The 2024 strategy maintained a safety profile comparable to that of the 2019 strategy while potentially reducing unnecessary CIT in patients presenting with SCP suggestive of chronic coronary syndrome (CCS).
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Jiang et al. (2026) conducted a cohort in Stable chest pain (n=17,612). 2024 ESC guideline risk assessment strategy vs. 2019 ESC guideline risk assessment strategy was evaluated on Major adverse cardiovascular events (MACEs) (NRI 6.11%, p=<0.001). The 2024 ESC risk assessment strategy safely increased imaging deferral compared to the 2019 strategy, yielding a net reclassification improvement of 6.11% (P<0.001) and an NNT of 17.
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