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

Borek Foldyna, James E. Udelson, Júlia Karády, Dahlia Banerji, Michael T. Lu, Thomas Mayrhofer, Daniel O. Bittner, Nandini M. Meyersohn, Hamed Emami, Tessa S.S. Genders, Christopher B. Fordyce, Maros Ferencik, Pamela S. Douglas, Udo Hoffmann

    Research output: Contribution to journalArticle

    15 Scopus citations

    Abstract

    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.

    Original languageEnglish (US)
    Article numberjey182
    Pages (from-to)574-581
    Number of pages8
    JournalEuropean heart journal cardiovascular Imaging
    Volume20
    Issue number5
    DOIs
    StatePublished - 2019

    Keywords

    • Diamond and Forrester
    • computed tomography angiography
    • coronary stenosis
    • obstructive coronary artery disease
    • stable chest pain

    ASJC Scopus subject areas

    • Radiology Nuclear Medicine and imaging
    • Cardiology and Cardiovascular Medicine

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  • Cite this

    Foldyna, B., Udelson, J. E., Karády, J., Banerji, D., Lu, M. T., Mayrhofer, T., Bittner, D. O., Meyersohn, N. M., Emami, H., Genders, T. S. S., Fordyce, C. B., Ferencik, M., Douglas, P. S., & Hoffmann, U. (2019). 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. European heart journal cardiovascular Imaging, 20(5), 574-581. [jey182]. https://doi.org/10.1093/ehjci/jey182