TY - JOUR
T1 - Pre-test probability of obstructive coronary stenosis in patients undergoing coronary CT angiography: Comparative performance of the modified diamond-Forrester algorithm versus methods incorporating cardiovascular risk factors
AU - Ferreira, Antonio Miguel
AU - Marques, Hugo
AU - Tralhao, Antonio
AU - Santos, Miguel Borges
AU - Santos, Ana Rita
AU - Cardoso, Goncalo
AU - Dores, Helder
AU - Carvalho, Maria Salome
AU - Madeira, Sergio
AU - Machado, Francisco Pereira
AU - Cardim, Nuno
AU - Gonçalves, Pedro de Araújo
PY - 2016/11/1
Y1 - 2016/11/1
N2 - Background: Current guidelines recommend the use of the Modified Diamond-Forrester (MDF) method to assess the pre-test likelihood of obstructive coronary artery disease (CAD). We aimed to compare the performance of the MDF method with two contemporary algorithms derived from multicenter trials that additionally incorporate cardiovascular risk factors: the calculator-based `CAD Consortium 2' method, and the integer-based CONFIRM score. Methods: We assessed 1069 consecutive patients without known CAD undergoing coronary CT angiography (CCTA) for stable chest pain. Obstructive CAD was defined as the presence of coronary stenosis textgreater= 50% on 64-slice dual-source CT. The three methods were assessed for calibration, discrimination, net reclassification, and changes in proposed downstream testing based upon calculated pre-test likelihoods. Results: The observed prevalence of obstructive CAD was 13.8% (n = 147). Overestimations of the likelihood of obstructive CAD were 140.1%, 9.8%, and 18.8%, respectively, for the MDF, CAD Consortium 2 and CONFIRM methods. The CAD Consortium 2 showed greater discriminative power than the MDF method, with a C-statistic of 0.73 vs. 0.70 (p textless 0.001), while the CONFIRM score did not (C-statistic 0.71, p = 0.492). Reclassification of pre-test likelihood using the `CAD Consortium 2' or CONFIRM scores resulted in a net reclassification improvement of 0.19 and 0.18, respectively, which would change the diagnostic strategy in approximately half of the patients. Conclusions: Newer risk factor-encompassing models allow for a more precise estimation of pre-test probabilities of obstructive CAD than the guideline-recommended MDF method. Adoption of these scores may improve disease prediction and change the diagnostic pathway in a significant proportion of patients. (C) 2016 Elsevier Ireland Ltd. All rights reserved.
AB - Background: Current guidelines recommend the use of the Modified Diamond-Forrester (MDF) method to assess the pre-test likelihood of obstructive coronary artery disease (CAD). We aimed to compare the performance of the MDF method with two contemporary algorithms derived from multicenter trials that additionally incorporate cardiovascular risk factors: the calculator-based `CAD Consortium 2' method, and the integer-based CONFIRM score. Methods: We assessed 1069 consecutive patients without known CAD undergoing coronary CT angiography (CCTA) for stable chest pain. Obstructive CAD was defined as the presence of coronary stenosis textgreater= 50% on 64-slice dual-source CT. The three methods were assessed for calibration, discrimination, net reclassification, and changes in proposed downstream testing based upon calculated pre-test likelihoods. Results: The observed prevalence of obstructive CAD was 13.8% (n = 147). Overestimations of the likelihood of obstructive CAD were 140.1%, 9.8%, and 18.8%, respectively, for the MDF, CAD Consortium 2 and CONFIRM methods. The CAD Consortium 2 showed greater discriminative power than the MDF method, with a C-statistic of 0.73 vs. 0.70 (p textless 0.001), while the CONFIRM score did not (C-statistic 0.71, p = 0.492). Reclassification of pre-test likelihood using the `CAD Consortium 2' or CONFIRM scores resulted in a net reclassification improvement of 0.19 and 0.18, respectively, which would change the diagnostic strategy in approximately half of the patients. Conclusions: Newer risk factor-encompassing models allow for a more precise estimation of pre-test probabilities of obstructive CAD than the guideline-recommended MDF method. Adoption of these scores may improve disease prediction and change the diagnostic pathway in a significant proportion of patients. (C) 2016 Elsevier Ireland Ltd. All rights reserved.
U2 - 10.1016/j.ijcard.2016.07.180
DO - 10.1016/j.ijcard.2016.07.180
M3 - Article
C2 - 27500762
VL - 222
SP - 346
EP - 351
JO - International Journal of Cardiology
JF - International Journal of Cardiology
SN - 0167-5273
ER -