Prediction of obstructive coronary artery disease and prognosis in patients with suspected stable angina

Jacob Reeh; Christina Bachmann Therming; Merete Heitmann; Søren Højberg; Charlotte Sørum; Jan Bech; Dorte Husum; Helena Dominguez; Thomas Sehestedt; Thomas Hermann; Kim Wadt Hansen; Lene Simonsen; Søren Galatius; Eva Prescott

doi:10.1093/eurheartj/ehy806

Prediction of obstructive coronary artery disease and prognosis in patients with suspected stable angina

Jacob Reeh, Christina Bachmann Therming, Merete Heitmann, Søren Højberg, Charlotte Sørum, Jan Bech, Dorte Husum, Helena Dominguez, Thomas Sehestedt, Thomas Hermann, Kim Wadt Hansen, Lene Simonsen, Søren Galatius, Eva Prescott

42 Citationer (Scopus)

Abstract

Aims We hypothesized that the modified Diamond–Forrester (D-F) prediction model overestimates probability of coronary artery disease (CAD). The aim of this study was to update the prediction model based on pre-test information and assess the model’s performance in predicting prognosis in an unselected, contemporary population suspected of angina. Methods We included 3903 consecutive patients free of CAD and heart failure and suspected of angina, who were referred and results to a single centre for assessment in 2012–15. Obstructive CAD was defined from invasive angiography as lesion requiring revascularization, >70% stenosis or fractional flow reserve <0.8. Patients were followed (mean follow-up 33 months) for myocardial infarction, unstable angina, heart failure, stroke, and death. The updated D-F prediction model overestimated probability considerably: mean pre-test probability was 31.4%, while only 274 (7%) were diagnosed with obstructive CAD. A basic prediction model with age, gender, and symptoms demonstrated good discrimination with C-statistics of 0.86 (95% CI 0.84–0.88), while a clinical prediction model adding diabetes, family history, and dyslipidaemia slightly improved the C-statistic to 0.88 (0.86–0.90) (P for difference between models <0.0001). Quartiles of probability of CAD from the clinical prediction model provided good diagnostic and prognostic stratification: in the lowest quartiles there were no cases of obstructive CAD and cumulative risk of the composite endpoint was less than 3% at 2 years. Conclusion The pre-test probability model recommended in current ESC guidelines substantially overestimates likelihood of CAD when applied to a contemporary, unselected, all-comer population. We provide an updated prediction model that identifies subgroups with low likelihood of obstructive CAD and good prognosis in which non-invasive testing may safely be deferred.

Originalsprog	Engelsk
Tidsskrift	European Heart Journal
Vol/bind	18
Udgave nummer	7
Sider (fra-til)	1426–1435
ISSN	0195-668X
DOI	https://doi.org/10.1093/eurheartj/ehy806
Status	Udgivet - 1 maj 2019

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10.1093/eurheartj/ehy806

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Reeh, J., Therming, C. B., Heitmann, M., Højberg, S., Sørum, C., Bech, J., Husum, D., Dominguez, H., Sehestedt, T., Hermann, T., Hansen, K. W., Simonsen, L., Galatius, S., & Prescott, E. (2019). Prediction of obstructive coronary artery disease and prognosis in patients with suspected stable angina. European Heart Journal, 18(7), 1426–1435. https://doi.org/10.1093/eurheartj/ehy806

Reeh, J, Therming, CB, Heitmann, M, Højberg, S, Sørum, C, Bech, J, Husum, D, Dominguez, H, Sehestedt, T, Hermann, T, Hansen, KW, Simonsen, L, Galatius, S & Prescott, E 2019, 'Prediction of obstructive coronary artery disease and prognosis in patients with suspected stable angina', European Heart Journal, bind 18, nr. 7, s. 1426–1435. https://doi.org/10.1093/eurheartj/ehy806

@article{2bfd920a424d481c8f22a5da4d60d843,

title = "Prediction of obstructive coronary artery disease and prognosis in patients with suspected stable angina",

abstract = "Aims We hypothesized that the modified Diamond–Forrester (D-F) prediction model overestimates probability of coronary artery disease (CAD). The aim of this study was to update the prediction model based on pre-test information and assess the model{\textquoteright}s performance in predicting prognosis in an unselected, contemporary population suspected of angina. Methods We included 3903 consecutive patients free of CAD and heart failure and suspected of angina, who were referred and results to a single centre for assessment in 2012–15. Obstructive CAD was defined from invasive angiography as lesion requiring revascularization, >70% stenosis or fractional flow reserve <0.8. Patients were followed (mean follow-up 33 months) for myocardial infarction, unstable angina, heart failure, stroke, and death. The updated D-F prediction model overestimated probability considerably: mean pre-test probability was 31.4%, while only 274 (7%) were diagnosed with obstructive CAD. A basic prediction model with age, gender, and symptoms demonstrated good discrimination with C-statistics of 0.86 (95% CI 0.84–0.88), while a clinical prediction model adding diabetes, family history, and dyslipidaemia slightly improved the C-statistic to 0.88 (0.86–0.90) (P for difference between models <0.0001). Quartiles of probability of CAD from the clinical prediction model provided good diagnostic and prognostic stratification: in the lowest quartiles there were no cases of obstructive CAD and cumulative risk of the composite endpoint was less than 3% at 2 years. Conclusion The pre-test probability model recommended in current ESC guidelines substantially overestimates likelihood of CAD when applied to a contemporary, unselected, all-comer population. We provide an updated prediction model that identifies subgroups with low likelihood of obstructive CAD and good prognosis in which non-invasive testing may safely be deferred.",

author = "Jacob Reeh and Therming, {Christina Bachmann} and Merete Heitmann and S{\o}ren H{\o}jberg and Charlotte S{\o}rum and Jan Bech and Dorte Husum and Helena Dominguez and Thomas Sehestedt and Thomas Hermann and Hansen, {Kim Wadt} and Lene Simonsen and S{\o}ren Galatius and Eva Prescott",

year = "2019",

month = may,

day = "1",

doi = "10.1093/eurheartj/ehy806",

language = "English",

volume = "18",

pages = "1426–1435",

journal = "European Heart Journal",

issn = "0195-668X",

publisher = "Oxford University Press",

number = "7",

}

TY - JOUR

T1 - Prediction of obstructive coronary artery disease and prognosis in patients with suspected stable angina

AU - Reeh, Jacob

AU - Therming, Christina Bachmann

AU - Heitmann, Merete

AU - Højberg, Søren

AU - Sørum, Charlotte

AU - Bech, Jan

AU - Husum, Dorte

AU - Dominguez, Helena

AU - Sehestedt, Thomas

AU - Hermann, Thomas

AU - Hansen, Kim Wadt

AU - Simonsen, Lene

AU - Galatius, Søren

AU - Prescott, Eva

PY - 2019/5/1

Y1 - 2019/5/1

N2 - Aims We hypothesized that the modified Diamond–Forrester (D-F) prediction model overestimates probability of coronary artery disease (CAD). The aim of this study was to update the prediction model based on pre-test information and assess the model’s performance in predicting prognosis in an unselected, contemporary population suspected of angina. Methods We included 3903 consecutive patients free of CAD and heart failure and suspected of angina, who were referred and results to a single centre for assessment in 2012–15. Obstructive CAD was defined from invasive angiography as lesion requiring revascularization, >70% stenosis or fractional flow reserve <0.8. Patients were followed (mean follow-up 33 months) for myocardial infarction, unstable angina, heart failure, stroke, and death. The updated D-F prediction model overestimated probability considerably: mean pre-test probability was 31.4%, while only 274 (7%) were diagnosed with obstructive CAD. A basic prediction model with age, gender, and symptoms demonstrated good discrimination with C-statistics of 0.86 (95% CI 0.84–0.88), while a clinical prediction model adding diabetes, family history, and dyslipidaemia slightly improved the C-statistic to 0.88 (0.86–0.90) (P for difference between models <0.0001). Quartiles of probability of CAD from the clinical prediction model provided good diagnostic and prognostic stratification: in the lowest quartiles there were no cases of obstructive CAD and cumulative risk of the composite endpoint was less than 3% at 2 years. Conclusion The pre-test probability model recommended in current ESC guidelines substantially overestimates likelihood of CAD when applied to a contemporary, unselected, all-comer population. We provide an updated prediction model that identifies subgroups with low likelihood of obstructive CAD and good prognosis in which non-invasive testing may safely be deferred.

AB - Aims We hypothesized that the modified Diamond–Forrester (D-F) prediction model overestimates probability of coronary artery disease (CAD). The aim of this study was to update the prediction model based on pre-test information and assess the model’s performance in predicting prognosis in an unselected, contemporary population suspected of angina. Methods We included 3903 consecutive patients free of CAD and heart failure and suspected of angina, who were referred and results to a single centre for assessment in 2012–15. Obstructive CAD was defined from invasive angiography as lesion requiring revascularization, >70% stenosis or fractional flow reserve <0.8. Patients were followed (mean follow-up 33 months) for myocardial infarction, unstable angina, heart failure, stroke, and death. The updated D-F prediction model overestimated probability considerably: mean pre-test probability was 31.4%, while only 274 (7%) were diagnosed with obstructive CAD. A basic prediction model with age, gender, and symptoms demonstrated good discrimination with C-statistics of 0.86 (95% CI 0.84–0.88), while a clinical prediction model adding diabetes, family history, and dyslipidaemia slightly improved the C-statistic to 0.88 (0.86–0.90) (P for difference between models <0.0001). Quartiles of probability of CAD from the clinical prediction model provided good diagnostic and prognostic stratification: in the lowest quartiles there were no cases of obstructive CAD and cumulative risk of the composite endpoint was less than 3% at 2 years. Conclusion The pre-test probability model recommended in current ESC guidelines substantially overestimates likelihood of CAD when applied to a contemporary, unselected, all-comer population. We provide an updated prediction model that identifies subgroups with low likelihood of obstructive CAD and good prognosis in which non-invasive testing may safely be deferred.

U2 - 10.1093/eurheartj/ehy806

DO - 10.1093/eurheartj/ehy806

M3 - Journal article

C2 - 30561616

SN - 0195-668X

VL - 18

SP - 1426

EP - 1435

JO - European Heart Journal

JF - European Heart Journal

IS - 7

ER -

Prediction of obstructive coronary artery disease and prognosis in patients with suspected stable angina

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