Pretest probability for patients with suspected obstructive coronary artery disease: re-evaluating Diamond-Forrester for the contemporary era and clinical implications: insights from the PROMISE trial.

Journal Article (Journal Article;Multicenter Study;Pragmatic Clinical Trial)

AIMS: To update pretest probabilities (PTP) for obstructive coronary artery disease (CAD ≥ 50%) across age, sex, and clinical symptom strata, using coronary computed tomography angiography (CTA) in a large contemporary population of patients with stable chest pain referred to non-invasive testing. METHODS AND RESULTS: We included patients enrolled in the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial and randomized to CTA. Exclusively level III-certified readers, blinded to demographic and clinical data, assessed the prevalence of CAD ≥ 50% in a central core lab. After comparing the recent European Society of Cardiology-Diamond and Forrester PTP (ESC-DF) with the actual observed prevalence of CAD ≥ 50%, we created a new PTP set by replacing the ESC-DF PTP with the observed prevalence of CAD ≥ 50% across strata of age, sex, and type of angina. In 4415 patients (48.3% men; 60.5 ± 8.2 years; 78% atypical angina; 11% typical angina; 11% non-anginal chest pain), the observed prevalence of CAD ≥ 50% was 13.9%, only one-third of the average ESC-DF PTP (40.6; P < 0.001 for difference). The PTP in the new set ranged 2-48% and were consistently lower than the ESC-DF PTP across all age, sex, and angina type categories. Initially, 4284/4415 (97%) patients were classified as intermediate-probability by the ESC-DF (PTP 15-85%); using the PROMISE-PTP, 50.2% of these patients were reclassified to the low PTP category (PTP < 15%). CONCLUSION: The ESC-DF PTP overestimate vastly the actual prevalence of CAD ≥ 50%. A new set of PTP, derived from results of non-invasive testing, may substantially reduce the need for non-invasive tests in stable chest pain.

Full Text

Duke Authors

Cited Authors

  • Foldyna, B; Udelson, JE; Karády, J; Banerji, D; Lu, MT; Mayrhofer, T; Bittner, DO; Meyersohn, NM; Emami, H; Genders, TSS; Fordyce, CB; Ferencik, M; Douglas, PS; Hoffmann, U

Published Date

  • May 1, 2019

Published In

Volume / Issue

  • 20 / 5

Start / End Page

  • 574 - 581

PubMed ID

  • 30520944

Pubmed Central ID

  • PMC6477645

Electronic International Standard Serial Number (EISSN)

  • 2047-2412

Digital Object Identifier (DOI)

  • 10.1093/ehjci/jey182


  • eng

Conference Location

  • England