TY - JOUR

T1 - Clinical pre-test probability for obstructive coronary artery disease

T2 - insights from the European DISCHARGE pilot study

AU - Feger, Sarah

AU - Ibes, Paolo

AU - Napp, Adriane E.

AU - Lembcke, Alexander

AU - Laule, Michael

AU - Dreger, Henryk

AU - Bokelmann, Björn

AU - Davis, Gershan K.

AU - Roditi, Giles

AU - Diez, Ignacio

AU - Schröder, Stephen

AU - Plank, Fabian

AU - Maurovich-Horvat, Pal

AU - Vidakovic, Radosav

AU - Veselka, Josef

AU - Ilnicka-Suckiel, Malgorzata

AU - Erglis, Andrejs

AU - Benedek, Teodora

AU - Rodriguez-Palomares, José

AU - Saba, Luca

AU - Kofoed, Klaus F.

AU - Gutberlet, Matthias

AU - Ađić, Filip

AU - Pietilä, Mikko

AU - Faria, Rita

AU - Vaitiekiene, Audrone

AU - Dodd, Jonathan D.

AU - Donnelly, Patrick

AU - Francone, Marco

AU - Kepka, Cezary

AU - Ruzsics, Balazs

AU - Müller-Nordhorn, Jacqueline

AU - Schlattmann, Peter

AU - Dewey, Marc

N1 - Funding Information: Patrick Donnelly: Dr. Donnelly reports grants from the European Commission, during the conduct of the study; grants from Southeastern Health and Social Care Trust Innovation Research Development Group Fund, outside the submitted work. Funding Information: Mikko Pietilä: Dr. Pietila reports grants from European Commission, during the conduct of the study; personal fees from AstraZeneca, personal fees from Novartis, personal fees from MSD, non-financial support from Bayer, and non-financial support from B. Braun, outside the submitted work. Funding Information: Teodora Benedek: Dr. Benedek reports grants from European Commission, during the conduct of the study; grants from Romanian Ministry of European Funds; the Romanian Government and the European Union; and grants from Romanian Ministry of European Funds, the Romanian Government, and the European Union, outside the submitted work. Funding Information: Marc Dewey: Dr. Dewey reports grants from the European Commission, other from Vital Images, other from AG Mednet, during the conduct of the study; grants from Siemens Medical Solutions; grants from GE Healthcare; grants from Toshiba Medical Systems; grants from Philips Medical Systems; and grants from Heisenberg Programme of DFG, outside the submitted work. Funding Information: Klaus Kofoed: Dr. Fuglsang Kofoed reports grants from European Commission, during the conduct of the study; grants from AP Møller og hustru Chastine McKinney Møllers Fond; grants from The John and Birthe Meyer Foundation; grants from Research Council of Rigshopitalet; grants from The University of Copenhagen; grants from The Danish Heart Foundation; grants from The Lundbeck Foundation; grants from The Danish Agency for Science, Technology and Innovation by The Danish Council for Strategic Research; grants from CATCH-2 trial; grants from CSub320 trial; and grants from Toshiba Medical Corporation, other from Toshiba Medical Corporation, outside the submitted work. Funding Information: The ethics approval for the main DISCHARGE trial (EA1/294/13) included the pilot study. Depending on local site requirements for data acquisition, written and/or oral informed consent was obtained from all patients participating in the DISCHARGE pilot study. The study participants did not undergo any follow-up examinations or investigational procedures. The DISCHARGE project is funded by the EU-FP7 Framework Programme (FP7 2007-2013, EC-GA 603266, EC-GA 603266) but the clinical sites did not receive any funding for the pilot study which was an own contribution by all. Only research staff at the coordinator site received funding for coordinating the pilot study. Funding Information: Rita Faria: Dr. Faria reports grants from the European Commission, during the conduct of the study; other from the Portuguese Ministry of Health, outside the submitted work. Funding Information: Andrejs Erglis: Dr. Erglis reports grants from European Commission, during the conduct of the study; grants from Abbott Vascular; grants from Boston Scientific; personal fees from Abbott Vascular; personal fees from Boston Scientific; personal fees from Biotronik; personal fees from Biosensors; personal fees from Cordis; and personal fees from Medtronik, outside the submitted work. Publisher Copyright: © 2020, The Author(s).

PY - 2021/3

Y1 - 2021/3

N2 - Objectives: To test the accuracy of clinical pre-test probability (PTP) for prediction of obstructive coronary artery disease (CAD) in a pan-European setting. Methods: Patients with suspected CAD and stable chest pain who were clinically referred for invasive coronary angiography (ICA) or computed tomography (CT) were included by clinical sites participating in the pilot study of the European multi-centre DISCHARGE trial. PTP of CAD was determined using the Diamond-Forrester (D+F) prediction model initially introduced in 1979 and the updated D+F model from 2011. Obstructive coronary artery disease (CAD) was defined by one at least 50% diameter coronary stenosis by both CT and ICA. Results: In total, 1440 patients (654 female, 786 male) were included at 25 clinical sites from May 2014 until July 2017. Of these patients, 725 underwent CT, while 715 underwent ICA. Both prediction models overestimated the prevalence of obstructive CAD (31.7%, 456 of 1440 patients, PTP: initial D+F 58.9% (28.1–90.6%), updated D+F 47.3% (34.2–59.9%), both p < 0.001), but overestimation of disease prevalence was higher for the initial D+F (p < 0.001). The discriminative ability was higher for the updated D+F 2011 (AUC of 0.73 95% confidence interval [CI] 0.70–0.76 versus AUC of 0.70 CI 0.67–0.73 for the initial D+F; p < 0.001; odds ratio (or) 1.55 CI 1.29–1.86, net reclassification index 0.11 CI 0.05–0.16, p < 0.001). Conclusions: Clinical PTP calculation using the initial and updated D+F prediction models relevantly overestimates the actual prevalence of obstructive CAD in patients with stable chest pain clinically referred for ICA and CT suggesting that further refinements to improve clinical decision-making are needed. Trial registration: https://www.clinicaltrials.gov/ct2/show/NCT02400229 Key Points: • Clinical pre-test probability calculation using the initial and updated D+F model overestimates the prevalence of obstructive CAD identified by ICA and CT. • Overestimation of disease prevalence is higher for the initial D+F compared with the updated D+F. • Diagnostic accuracy of PTP assessment varies strongly between different clinical sites throughout Europe.

AB - Objectives: To test the accuracy of clinical pre-test probability (PTP) for prediction of obstructive coronary artery disease (CAD) in a pan-European setting. Methods: Patients with suspected CAD and stable chest pain who were clinically referred for invasive coronary angiography (ICA) or computed tomography (CT) were included by clinical sites participating in the pilot study of the European multi-centre DISCHARGE trial. PTP of CAD was determined using the Diamond-Forrester (D+F) prediction model initially introduced in 1979 and the updated D+F model from 2011. Obstructive coronary artery disease (CAD) was defined by one at least 50% diameter coronary stenosis by both CT and ICA. Results: In total, 1440 patients (654 female, 786 male) were included at 25 clinical sites from May 2014 until July 2017. Of these patients, 725 underwent CT, while 715 underwent ICA. Both prediction models overestimated the prevalence of obstructive CAD (31.7%, 456 of 1440 patients, PTP: initial D+F 58.9% (28.1–90.6%), updated D+F 47.3% (34.2–59.9%), both p < 0.001), but overestimation of disease prevalence was higher for the initial D+F (p < 0.001). The discriminative ability was higher for the updated D+F 2011 (AUC of 0.73 95% confidence interval [CI] 0.70–0.76 versus AUC of 0.70 CI 0.67–0.73 for the initial D+F; p < 0.001; odds ratio (or) 1.55 CI 1.29–1.86, net reclassification index 0.11 CI 0.05–0.16, p < 0.001). Conclusions: Clinical PTP calculation using the initial and updated D+F prediction models relevantly overestimates the actual prevalence of obstructive CAD in patients with stable chest pain clinically referred for ICA and CT suggesting that further refinements to improve clinical decision-making are needed. Trial registration: https://www.clinicaltrials.gov/ct2/show/NCT02400229 Key Points: • Clinical pre-test probability calculation using the initial and updated D+F model overestimates the prevalence of obstructive CAD identified by ICA and CT. • Overestimation of disease prevalence is higher for the initial D+F compared with the updated D+F. • Diagnostic accuracy of PTP assessment varies strongly between different clinical sites throughout Europe.

KW - Computed tomography angiography

KW - Coronary artery disease

KW - Prevalence

KW - Probability of disease

U2 - 10.1007/s00330-020-07175-z

DO - 10.1007/s00330-020-07175-z

M3 - Journal article

C2 - 32902743

AN - SCOPUS:85090461170

VL - 31

SP - 1471

EP - 1481

JO - European Radiology

JF - European Radiology

SN - 0938-7994

IS - 3

ER -