CTCA reduced 5-year coronary events compared to standard care, with the greatest difference in patients with a pre-test probability >15% (2.8% vs. 5.3%, P=0.01).
RCT (n=3,755)
Yes
Does the 2019 ESC pre-test probability accurately predict obstructive coronary artery disease and help select patients for CTCA versus standard care?
The 2019 ESC pre-test probability slightly underestimates obstructive CAD prevalence but effectively stratifies risk for future coronary events and identifies patients who may benefit most from CTCA.
Absolute Event Rate: 2.8% vs 5.3%
p-value: p=0.01
AIMS: To assess contemporary pre-test probability estimates for obstructive coronary artery disease in patients with stable chest pain. METHODS AND RESULTS: In this substudy of a multicentre randomized controlled trial, we compared 2019 European Society of Cardiology (ESC)-endorsed pre-test probabilities with observed prevalence of obstructive coronary artery disease on computed tomography coronary angiography (CTCA). We assessed associations between pre-test probability, 5-year coronary heart disease death or non-fatal myocardial infarction and study intervention (standard care vs. CTCA). The study population consisted of 3755 patients (30-75 years, 46% women) with a median pre-test probability of 11% of whom 1622 (43%) had a pre-test probability of >15%. In those who underwent CTCA (n = 1613), the prevalence of obstructive disease was 22%. When divided into deciles of pre-test probability, the observed disease prevalence was similar but higher than the corresponding median pre-test probability median difference 2.3 (1.3-5.6)%. There were more clinical events in patients with a pre-test probability >15% compared to those at 5-15% and 15% (2.8% vs. 5.3%, log rank P = 0.01), although this interaction was not statistically significant on multivariable modelling. CONCLUSION: The updated 2019 ESC guideline pre-test probability recommendations tended to slightly underestimate disease prevalence in our cohort. Pre-test probability is a powerful predictor of future coronary events and helps select those who may derive the greatest absolute benefit from CTCA.
Bing et al. (2020) conducted an RCT in suspected stable angina (n=3,755). Computed tomography coronary angiography (CTCA) vs. Standard care was evaluated on 5-year coronary heart disease death or non-fatal myocardial infarction (p=0.01). CTCA reduced 5-year coronary events compared to standard care, with the greatest difference in patients with a pre-test probability >15% (2.8% vs. 5.3%, P=0.01).
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