Incorporating Coronary Calcification Into Pre-Test Assessment of the Likelihood of Coronary Artery Disease.

Journal Article (Journal Article)

BACKGROUND: The prevalence of obstructive coronary artery disease (CAD) in symptomatic patients referred for diagnostic testing has declined, warranting optimization of individualized diagnostic strategies. OBJECTIVES: This study sought to present a simple, clinically applicable tool enabling estimation of the likelihood of obstructive CAD by combining a pre-test probability (PTP) model (Diamond-Forrester approach using sex, age, and symptoms) with clinical risk factors and coronary artery calcium score (CACS). METHODS: The new tool was developed in a cohort of symptomatic patients (n = 41,177) referred for diagnostic testing. The risk factor-weighted clinical likelihood (RF-CL) was calculated through PTP and risk factors, while the CACS-weighted clinical likelihood (CACS-CL) added CACS. The 2 calculation models were validated in European and North American cohorts (n = 15,411) and compared with a recently updated PTP table. RESULTS: The RF-CL and CACS-CL models predicted the prevalence of obstructive CAD more accurately in the validation cohorts than the PTP model, and markedly increased the area under the receiver-operating characteristic curves of obstructive CAD: for the PTP model, 72 (95% confidence intervals [CI]: 71 to 74); for the RF-CL model, 75 (95% CI: 74 to 76); and for the CACS-CL model, 85 (95% CI: 84 to 86). In total, 38% of the patients in the RF-CL group and 54% in the CACS-CL group were categorized as having a low clinical likelihood of CAD, as compared with 11% with the PTP model. CONCLUSIONS: A simple risk factor and CACS-CL tool enables improved prediction and discrimination of patients with suspected obstructive CAD. The tool empowers reclassification of patients to low likelihood of CAD, who need no further testing.

Full Text

Duke Authors

Cited Authors

  • Winther, S; Schmidt, SE; Mayrhofer, T; Bøtker, HE; Hoffmann, U; Douglas, PS; Wijns, W; Bax, J; Nissen, L; Lynggaard, V; Christiansen, JJ; Saraste, A; Bøttcher, M; Knuuti, J

Published Date

  • November 24, 2020

Published In

Volume / Issue

  • 76 / 21

Start / End Page

  • 2421 - 2432

PubMed ID

  • 33213720

Electronic International Standard Serial Number (EISSN)

  • 1558-3597

Digital Object Identifier (DOI)

  • 10.1016/j.jacc.2020.09.585


  • eng

Conference Location

  • United States