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Int J Cardiol. 2016 Nov 1;222:346-351. doi: 10.1016/j.ijcard.2016.07.180. Epub 2016 Jul 30.

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.

Author information

1
Cardiovascular Imaging Unit, Hospital da Luz, Avenida Lusíada 100, Lisbon, Portugal; Cardiology Department, Carnaxide, Portugal. Electronic address: antonio.ferreira@hospitaldaluz.pt.
2
Cardiovascular Imaging Unit, Hospital da Luz, Avenida Lusíada 100, Lisbon, Portugal.
3
Cardiovascular Imaging Unit, Hospital da Luz, Avenida Lusíada 100, Lisbon, Portugal; Cardiology Department, Carnaxide, Portugal.
4
Cardiovascular Imaging Unit, Hospital da Luz, Avenida Lusíada 100, Lisbon, Portugal; Cardiology Department, Hospital Distrital de Évora, Largo Senhor da Pobreza, Évora, Portugal.
5
Cardiovascular Imaging Unit, Hospital da Luz, Avenida Lusíada 100, Lisbon, Portugal; Cardiology Department, Carnaxide, Portugal; CEDOC, Chronic Diseases Research Center, FCM-NOVA, Lisbon, Portugal.

Abstract

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 ≥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<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.

KEYWORDS:

Coronary CT angiography; Coronary artery disease; Diagnosis; Pre-test probability; Validation

PMID:
27500762
DOI:
10.1016/j.ijcard.2016.07.180
[Indexed for MEDLINE]

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