The exercise electrocardiography-weighted clinical likelihood model provided similar discrimination of obstructive coronary artery disease compared to the risk factor-weighted model (AUC 83.1% vs 80.7%, p=0.14) but significantly reclassified more patients to a very-low clinical likelihood group.
Cohort (n=3,691)
Yes
Does an ExECG-weighted clinical likelihood model improve discrimination and reclassification of obstructive CAD compared to a risk factor-weighted model in patients with suspected CAD?
Incorporating exercise ECG into a clinical likelihood model improves the reclassification of patients with suspected CAD into a very-low risk category, potentially safely reducing the need for downstream testing.
Absolute Event Rate: 83.1% vs 80.7%
p-value: p=0.14
OBJECTIVES: To develop a tool including exercise electrocardiography (ExECG) for patient-specific clinical likelihood estimation of patients with suspected obstructive coronary artery disease (CAD). METHODS: An ExECG-weighted clinical likelihood (ExECG-CL) model was developed in a training cohort of patients with suspected obstructive CAD undergoing ExECG. Next, the ExECG-CL model was applied in a CAD validation cohort undergoing ExECG and clinically driven invasive coronary angiography and a prognosis validation cohort and compared with the risk factor-weighted clinical likelihood (RF-CL) model for obstructive CAD discrimination and prognostication, respectively.In the CAD validation cohort, obstructive CAD was defined as >50% diameter stenosis on invasive coronary angiography. For prognosis, the endpoint was non-fatal myocardial infarction and death. RESULTS: The training cohort consisted of 1214 patients (mean age 57 years, 57% males). In the CAD (N=408; mean age 55 years, 53% males) and prognosis validation (N=3283; mean age 57 years, 57% males) cohorts, 11.8% patients had obstructive CAD and 4.4% met the endpoint. In the CAD validation cohort, discrimination of obstructive CAD was similar between the ExECG-CL and RF-CL models: area under the receiver-operating characteristic curves 83.1% (95% CIs 77.5% to 88.7%) versus 80.7% (95% CI 74.6% to 86.8%), p=0.14. In the ExECG-CL model, more patients had very low (≤5%) clinical likelihood of obstructive CAD compared with the RF-CL (42.2% vs 36.0%, p<0.01) where obstructive CAD prevalence and event risk remained low. CONCLUSIONS: ExECG incorporated into a clinical likelihood model improves reclassification of patients to a very low clinical likelihood group with very low prevalence of obstructive CAD and favourable prognosis.
Rasmussen et al. (2023) conducted a cohort in Suspected obstructive coronary artery disease (n=3,691). Exercise electrocardiography-weighted clinical likelihood (ExECG-CL) model vs. Risk factor-weighted clinical likelihood (RF-CL) model was evaluated on Discrimination of obstructive CAD (>50% diameter stenosis on invasive coronary angiography) measured by AUC (95% CI 77.5-88.7, p=0.14). The exercise electrocardiography-weighted clinical likelihood model provided similar discrimination of obstructive coronary artery disease compared to the risk factor-weighted model (AUC 83.1% vs 80.7%, p=0.14) but significantly reclassified more patients to a very-low clinical likelihood group.