Clinical Likelihood Prediction of Hemodynamically Obstructive Coronary Artery Disease in Patients With Stable Chest Pain

Laust Dupont Rasmussen*, Salma Raghad Karim, Jelmer Westra, Louise Nissen, Jonathan Nørtoft Dahl, Gitte Stokvad Brix, Juhani Knuuti, Samuel Emil Schmidt, Niels Ramsing Holm, Evald Høj Christiansen, Ashkan Eftekhari, Morten Bøttcher, Simon Winther

*Corresponding author for this work

Research output: Contribution to journalJournal articleResearchpeer-review

3 Citations (Scopus)

Abstract

Background
Selection for invasive angiography is recommended to be based on pretest probabilities (PTPs), and physiological measures of hemodynamical impairment by, for example, fractional flow reserve (FFR) should guide revascularization. The risk factor–weighted clinical likelihood (RF-CL) and coronary artery calcium score–weighted clinical likelihood (CACS-CL) models show superior discrimination of patients with suspected obstructive coronary artery disease (CAD), but validation against hemodynamic impairment is warranted.

Objectives
The aim of this study was to validate the RF-CL and CACS-CL models against hemodynamically obstructive CAD.

Methods
Stable de novo chest pain patients (N = 4,371) underwent coronary computed tomography angiography and subsequently invasive coronary angiography with FFR measurements. Hemodynamically obstructive CAD was defined as invasive FFR ≤0.80 or high-grade stenosis by visual assessment (>90% diameter stenosis). For comparison, a guideline-endorsed basic PTP model was calculated based on age, sex, and symptom typicality. The RF-CL model additionally included the number of risk factors, and the CACS-CL model incorporated the coronary artery calcium score into the RF-CL.

Results
In total, 447 of 4,371 (10.9%) patients had hemodynamically obstructive CAD. Both the RF-CL and CACS-CL models classified more patients with a very low clinical likelihood (≤5%) of obstructive CAD compared to the basic PTP model (33.0% and 53.7% vs 12.0%; P < 0.001) with a preserved low prevalence of hemodynamically obstructive CAD (<5% for all models). Against hemodynamically obstructive CAD, calibration and discrimination of the RF-CL and CACS-CL models were superior to the basic PTP model.

Conclusions
The RF-CL and CACS-CL models are well calibrated and superior to a currently recommended basic PTP model to predict hemodynamically obstructive CAD. (Danish Study of Non-Invasive Diagnostic Testing in Coronary Artery Disease [Dan-NICAD]; NCT02264717; Danish Study of Non-Invasive Diagnostic Testing in Coronary Artery Disease 2 [Dan-NICAD 2]; NCT03481712, Danish Study of Non-Invasive Diagnostic Testing in Coronary Artery Disease 3 [Dan-NICAD 3]; NCT04707859)
Original languageEnglish
JournalJACC. Cardiovascular imaging
Volume17
Issue number10
Pages (from-to)1199-1210
Number of pages12
ISSN1936-878X
DOIs
Publication statusPublished - Oct 2024

Bibliographical note

Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Keywords

  • chronic coronary syndrome
  • clinical likelihood
  • coronary artery disease
  • invasive fractional flow reserve
  • pretest probability

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