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Gibbons RJ. Recommendations for Deferred Testing in Low-Risk Chest Pain-Decades Old But Now Finally Tested. JAMA Cardiol 2023; 8:924-926. [PMID: 37610740 DOI: 10.1001/jamacardio.2023.2715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
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Udelson JE, Kelsey MD, Nanna MG, Fordyce CB, Yow E, Clare RM, Mark DB, Patel MR, Rogers C, Curzen N, Pontone G, Maurovich-Horvat P, De Bruyne B, Greenwood JP, Marinescu V, Leipsic J, Stone GW, Ben-Yehuda O, Berry C, Hogan SE, Redfors B, Ali ZA, Byrne RA, Kramer CM, Yeh RW, Martinez B, Mullen S, Huey W, Anstrom KJ, Al-Khalidi HR, Chiswell K, Vemulapalli S, Douglas PS. Deferred Testing in Stable Outpatients With Suspected Coronary Artery Disease: A Prespecified Secondary Analysis of the PRECISE Randomized Clinical Trial. JAMA Cardiol 2023; 8:915-924. [PMID: 37610768 PMCID: PMC10448368 DOI: 10.1001/jamacardio.2023.2614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 06/26/2023] [Indexed: 08/24/2023]
Abstract
Importance Guidelines recommend deferral of testing for symptomatic people with suspected coronary artery disease (CAD) and low pretest probability. To our knowledge, no randomized trial has prospectively evaluated such a strategy. Objective To assess process of care and health outcomes in people identified as minimal risk for CAD when testing is deferred. Design, Setting, and Participants This randomized, pragmatic effectiveness trial included prespecified subgroup analysis of the PRECISE trial at 65 North American and European sites. Participants identified as minimal risk by the validated PROMISE minimal risk score (PMRS) were included. Intervention Randomization to a precision strategy using the PMRS to assign those with minimal risk to deferred testing and others to coronary computed tomography angiography with selective computed tomography-derived fractional flow reserve, or to usual testing (stress testing or catheterization with PMRS masked). Randomization was stratified by PMRS risk. Main Outcome Composite of all-cause death, nonfatal myocardial infarction (MI), or catheterization without obstructive CAD through 12 months. Results Among 2103 participants, 422 were identified as minimal risk (20%) and randomized to deferred testing (n = 214) or usual testing (n = 208). Mean age (SD) was 46 (8.6) years; 304 were women (72%). During follow-up, 138 of those randomized to deferred testing never had testing (64%), whereas 76 had a downstream test (36%) (at median [IQR] 48 [15-78] days) for worsening (30%), uncontrolled (10%), or new symptoms (6%), or changing clinician preference (19%) or participant preference (10%). Results were normal for 96% of these tests. The primary end point occurred in 2 deferred testing (0.9%) and 13 usual testing participants (6.3%) (hazard ratio, 0.15; 95% CI, 0.03-0.66; P = .01). No death or MI was observed in the deferred testing participants, while 1 noncardiovascular death and 1 MI occurred in the usual testing group. Two participants (0.9%) had catheterizations without obstructive CAD in the deferred testing group and 12 (5.8%) with usual testing (P = .02). At baseline, 70% of participants had frequent angina and there was similar reduction of frequent angina to less than 20% at 12 months in both groups. Conclusion and Relevance In symptomatic participants with suspected CAD, identification of minimal risk by the PMRS guided a strategy of initially deferred testing. The strategy was safe with no observed adverse outcome events, fewer catheterizations without obstructive CAD, and similar symptom relief compared with usual testing. Trial Registration ClinicalTrials.gov Identifier: NCT03702244.
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Affiliation(s)
- James E. Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Michelle D. Kelsey
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Michael G. Nanna
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Christopher B. Fordyce
- Division of Cardiology, Department of Medicine, and Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Yow
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Robert M. Clare
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Daniel B. Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Manesh R. Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | | | - Nick Curzen
- Faculty of Medicine, University of Southampton and Cardiothoracic Unit, University Hospital Southampton, Southampton, United Kingdom
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino Instituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, and Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, Onze Lieve Vrouwziekenhuis-Clinic, Aalst, Belgium
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - John P. Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, and Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Victor Marinescu
- Midwest Cardiovascular Institute, Chicago Medical School, Edward-Elmhurst Health, Naperville, Illinois
- Edward-Elmhurst Health, Naperville, Illinois
| | - Jonathon Leipsic
- Departments of Radiology and Medicine (Cardiology), University of British Columbia, Vancouver, British Columbia, Canada
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, United Kingdom
| | - Shea E. Hogan
- CPC Clinical Research, and University of Colorado School of Medicine, Aurora
| | - Bjorn Redfors
- Cardiovascular Research Foundation, New York, New York
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ziad A. Ali
- St Francis Hospital & Heart Center, Roslyn, New York
| | - Robert A. Byrne
- Department of Cardiology and Cardiovascular Research Institute Dublin, Mater Private Network, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Beth Martinez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | | | | | - Hussein R. Al-Khalidi
- Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Pamela S. Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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Douglas PS, Nanna MG, Kelsey MD, Yow E, Mark DB, Patel MR, Rogers C, Udelson JE, Fordyce CB, Curzen N, Pontone G, Maurovich-Horvat P, De Bruyne B, Greenwood JP, Marinescu V, Leipsic J, Stone GW, Ben-Yehuda O, Berry C, Hogan SE, Redfors B, Ali ZA, Byrne RA, Kramer CM, Yeh RW, Martinez B, Mullen S, Huey W, Anstrom KJ, Al-Khalidi HR, Vemulapalli S. Comparison of an Initial Risk-Based Testing Strategy vs Usual Testing in Stable Symptomatic Patients With Suspected Coronary Artery Disease: The PRECISE Randomized Clinical Trial. JAMA Cardiol 2023; 8:904-914. [PMID: 37610731 PMCID: PMC10448364 DOI: 10.1001/jamacardio.2023.2595] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/26/2023] [Indexed: 08/24/2023]
Abstract
Importance Trials showing equivalent or better outcomes with initial evaluation using coronary computed tomography angiography (cCTA) compared with stress testing in patients with stable chest pain have informed guidelines but raise questions about overtesting and excess catheterization. Objective To test a modified initial cCTA strategy designed to improve clinical efficiency vs usual testing (UT). Design, Setting, and Participants This was a pragmatic randomized clinical trial enrolling participants from December 3, 2018, to May 18, 2021, with a median of 11.8 months of follow-up. Patients from 65 North American and European sites with stable symptoms of suspected coronary artery disease (CAD) and no prior testing were randomly assigned 1:1 to precision strategy (PS) or UT. Interventions PS incorporated the Prospective Multicenter Imaging Study for the Evaluation of Chest Pain (PROMISE) minimal risk score to quantitatively select minimal-risk participants for deferred testing, assigning all others to cCTA with selective CT-derived fractional flow reserve (FFR-CT). UT included site-selected stress testing or catheterization. Site clinicians determined subsequent care. Main Outcomes and Measures Outcomes were clinical efficiency (invasive catheterization without obstructive CAD) and safety (death or nonfatal myocardial infarction [MI]) combined into a composite primary end point. Secondary end points included safety components of the primary outcome and medication use. Results A total of 2103 participants (mean [SD] age, 58.4 [11.5] years; 1056 male [50.2%]) were included in the study, and 422 [20.1%] were classified as minimal risk. The primary end point occurred in 44 of 1057 participants (4.2%) in the PS group and in 118 of 1046 participants (11.3%) in the UT group (hazard ratio [HR], 0.35; 95% CI, 0.25-0.50). Clinical efficiency was higher with PS, with lower rates of catheterization without obstructive disease (27 [2.6%]) vs UT participants (107 [10.2%]; HR, 0.24; 95% CI, 0.16-0.36). The safety composite of death/MI was similar (HR, 1.52; 95% CI, 0.73-3.15). Death occurred in 5 individuals (0.5%) in the PS group vs 7 (0.7%) in the UT group (HR, 0.71; 95% CI, 0.23-2.23), and nonfatal MI occurred in 13 individuals (1.2%) in the PS group vs 5 (0.5%) in the UT group (HR, 2.65; 95% CI, 0.96-7.36). Use of lipid-lowering (450 of 900 [50.0%] vs 365 of 873 [41.8%]) and antiplatelet (321 of 900 [35.7%] vs 237 of 873 [27.1%]) medications at 1 year was higher in the PS group compared with the UT group (both P < .001). Conclusions and Relevance An initial diagnostic approach to stable chest pain starting with quantitative risk stratification and deferred testing for minimal-risk patients and cCTA with selective FFR-CT in all others increased clinical efficiency relative to UT at 1 year. Additional randomized clinical trials are needed to verify these findings, including safety. Trial Registration ClinicalTrials.gov Identifier: NCT03702244.
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Affiliation(s)
- Pamela S. Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Michael G. Nanna
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Michelle D. Kelsey
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Eric Yow
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Daniel B. Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Manesh R. Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | | | - James E. Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Christopher B. Fordyce
- Division of Cardiology, Department of Medicine, Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nick Curzen
- Faculty of Medicine, University of Southampton, Cardiothoracic Unit, University Hospital Southampton, Southampton, United Kingdom
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino Instituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, Onze Lieve Vrouwziekenhuis Clinic, Aalst, Belgium
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - John P. Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, United Kingdom
| | - Victor Marinescu
- Midwest Cardiovascular Institute, Chicago Medical School, Edward-Elmhurst Health, Naperville, Illinois
| | - Jonathon Leipsic
- Departments of Radiology and Medicine (Cardiology), University of British Columbia, Vancouver, British Columbia, Canada
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, United Kingdom
| | - Shea E. Hogan
- CPC Clinical Research, University of Colorado School of Medicine, Aurora
| | - Bjorn Redfors
- Cardiovascular Research Foundation, New York, New York
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ziad A. Ali
- St Francis Hospital & Heart Center, Roslyn, New York
| | - Robert A. Byrne
- Department of Cardiology, Cardiovascular Research Institute Dublin, Mater Private Network, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Beth Martinez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | | | | | - Hussein R. Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
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Møller PL, Rohde PD, Dahl JN, Rasmussen LD, Schmidt SE, Nissen L, McGilligan V, Bentzon JF, Gudbjartsson DF, Stefansson K, Holm H, Winther S, Bøttcher M, Nyegaard M. Combining Polygenic and Proteomic Risk Scores With Clinical Risk Factors to Improve Performance for Diagnosing Absence of Coronary Artery Disease in Patients With de novo Chest Pain. CIRCULATION. GENOMIC AND PRECISION MEDICINE 2023; 16:442-451. [PMID: 37753640 DOI: 10.1161/circgen.123.004053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/11/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Patients with de novo chest pain, referred for evaluation of possible coronary artery disease (CAD), frequently have an absence of CAD resulting in millions of tests not having any clinical impact. The objective of this study was to investigate whether polygenic risk scores and targeted proteomics improve the prediction of absence of CAD in patients with suspected CAD, when added to the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) minimal risk score (PMRS). METHODS Genotyping and targeted plasma proteomics (N=368 proteins) were performed in 1440 patients with symptoms suspected to be caused by CAD undergoing coronary computed tomography angiography. Based on individual genotypes, a polygenic risk score for CAD (PRSCAD) was calculated. The prediction was performed using combinations of PRSCAD, proteins, and PMRS as features in models using stability selection and machine learning. RESULTS Prediction of absence of CAD yielded an area under the curve of PRSCAD-model, 0.64±0.03; proteomic-model, 0.58±0.03; and PMRS model, 0.76±0.02. No significant correlation was found between the genetic and proteomic risk scores (Pearson correlation coefficient, -0.04; P=0.13). Optimal predictive ability was achieved by the full model (PRSCAD+protein+PMRS) yielding an area under the curve of 0.80±0.02 for absence of CAD, significantly better than the PMRS model alone (P<0.001). For reclassification purpose, the full model enabled down-classification of 49% (324 of 661) of the 5% to 15% pretest probability patients and 18% (113 of 611) of >15% pretest probability patients. CONCLUSIONS For patients with chest pain and low-intermediate CAD risk, incorporating targeted proteomics and polygenic risk scores into the risk assessment substantially improved the ability to predict the absence of CAD. Genetics and proteomics seem to add complementary information to the clinical risk factors and improve risk stratification in this large patient group. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02264717.
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Affiliation(s)
- Peter Loof Møller
- Department of Biomedicine (P.L.M., M.N.), Aarhus University
- Department of Health Science and Technology, Aalborg University (P.L.M., P.D.R., S.E.S., M.N.)
| | - Palle Duun Rohde
- Department of Health Science and Technology, Aalborg University (P.L.M., P.D.R., S.E.S., M.N.)
| | - Jonathan Nørtoft Dahl
- Department of Clinical Medicine (J.N.D., L.D.R., L.N., J.F.B., S.W., M.B.), Aarhus University
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark (J.N.D., L.D.R., L.N., S.W., M.B.)
| | - Laust Dupont Rasmussen
- Department of Clinical Medicine (J.N.D., L.D.R., L.N., J.F.B., S.W., M.B.), Aarhus University
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark (J.N.D., L.D.R., L.N., S.W., M.B.)
| | - Samuel Emil Schmidt
- Department of Health Science and Technology, Aalborg University (P.L.M., P.D.R., S.E.S., M.N.)
| | - Louise Nissen
- Department of Clinical Medicine (J.N.D., L.D.R., L.N., J.F.B., S.W., M.B.), Aarhus University
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark (J.N.D., L.D.R., L.N., S.W., M.B.)
| | - Victoria McGilligan
- Personalized Medicine Centre, Ulster University, Derry, Northern Ireland (V.M.)
| | - Jacob F Bentzon
- Department of Clinical Medicine (J.N.D., L.D.R., L.N., J.F.B., S.W., M.B.), Aarhus University
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain (J.F.B.)
| | - Daniel F Gudbjartsson
- deCODE genetics/Amgen, Inc. (D.F.G., K.S., H.H.)
- School of Engineering and Natural Sciences (D.F.G.)
| | - Kari Stefansson
- deCODE genetics/Amgen, Inc. (D.F.G., K.S., H.H.)
- Faculty of Medicine, University of Iceland, Reykjavik (K.S.)
| | - Hilma Holm
- deCODE genetics/Amgen, Inc. (D.F.G., K.S., H.H.)
| | - Simon Winther
- Department of Clinical Medicine (J.N.D., L.D.R., L.N., J.F.B., S.W., M.B.), Aarhus University
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark (J.N.D., L.D.R., L.N., S.W., M.B.)
| | - Morten Bøttcher
- Department of Clinical Medicine (J.N.D., L.D.R., L.N., J.F.B., S.W., M.B.), Aarhus University
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark (J.N.D., L.D.R., L.N., S.W., M.B.)
| | - Mette Nyegaard
- Department of Biomedicine (P.L.M., M.N.), Aarhus University
- Department of Health Science and Technology, Aalborg University (P.L.M., P.D.R., S.E.S., M.N.)
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Zhou J, Xin T, Tan Y, Pang J, Chen T, Wang H, Zhao J, Liu C, Xie C, Wang M, Wang C, Liu Y, Zhang J, Liu Y, Shanfu C, Li C, Cong H. Comparison of two diagnostic strategies for patients with stable chest pain suggestive of chronic coronary syndrome: rationale and design of the double-blind, pragmatic, randomized and controlled OPERATE Trial. BMC Cardiovasc Disord 2023; 23:416. [PMID: 37612631 PMCID: PMC10464280 DOI: 10.1186/s12872-023-03424-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 08/01/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND To achieve potential financial savings and avoid exposing the patients to unnecessary risk, an optimal diagnostic strategy to identify low risk individual who may derive minimal benefit from further cardiac imaging testing (CIT) is important for patients with stable chest pain (SCP) suggestive of chronic coronary syndrome (CCS). Although several diagnostic strategies have been recommended by the most recent guidelines, few randomized controlled trials (RCTs) have prospectively investigated the actual effect of applying these strategies in clinical practice. METHODS OPERATE (OPtimal Evaluation of stable chest pain to Reduce unnecessAry utilization of cardiac imaging TEsting) trial is an investigator-initiated, multicenter, coronary computed tomography angiography (CCTA)-based, 2-arm parallel-group, double-blind, pragmatic and confirmative RCT planning to include 800 subjects with SCP suggestive of CCS. After enrollment, all subjects will be randomized to two arms (2016 U.K. National Institute of Health and Care Excellence guideline-determined and 2019 European Society of Cardiology guideline-determined diagnostic strategy) on a 1:1 basis. According to each strategy, CCTA should be referred and deferred for a subject in high and low risk group, respectively. The primary (effectiveness) endpoint is CCTA without obstructive coronary artery disease. Safety of each strategy will be mainly assessed by 1-year major adverse cardiovascular event rates. DISCUSSION The OPERATE trial will provide comparative effectiveness and safety evidences for two different diagnostic strategies for patients with SCP suggestive of CCS, with the intension of improving the diagnostic yield of CCTA at no expense of safety. CLINICAL TRIAL REGISTRATION ClinicalTrial.org Identifier NCT05640752.
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Affiliation(s)
- Jia Zhou
- Clinical School of Thoracic, Tianjin Medical University, Tianjin, China.
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China.
| | - Ting Xin
- Department of Cardiology, Tianjin First Central Hospital, Tianjin, China
| | - Yahang Tan
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jianzhong Pang
- Department of Cardiology, Tianjin Second Teaching Hospital of Tianjin University of Traditional Chinese, Tianjin, China
| | - Tao Chen
- Department of Emergency, Hebei Petrochina Central Hospital, Langfang, Hebei, China
| | - Hao Wang
- Department of Clinical Epidemiology and Evidence-Based Medicine, Friendship Hospital, Capital Medical University, Beijing, China
| | - Jia Zhao
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Chang Liu
- Clinical School of Thoracic, Tianjin Medical University, Tianjin, China
| | - Cun Xie
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Minghui Wang
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Chengjian Wang
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Yuanying Liu
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Jie Zhang
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Yankun Liu
- Department of Cardiology, Tianjin Second Teaching Hospital of Tianjin University of Traditional Chinese, Tianjin, China
| | - Chen Shanfu
- Department of Cardiology, Tianjin Second Teaching Hospital of Tianjin University of Traditional Chinese, Tianjin, China
| | - Chunjie Li
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Hongliang Cong
- Clinical School of Thoracic, Tianjin Medical University, Tianjin, China.
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China.
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Playford D, Schwarz N, Williamson AE, Duong M, Shadmaan A, Turner D, Behncken S, Phillips T, Kearney L. Early outcomes following integration of computed tomography (CT) coronary angiography service in an established cardiology practice in disease management. J Cardiovasc Comput Tomogr 2023; 17:254-260. [PMID: 37210242 DOI: 10.1016/j.jcct.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/20/2023] [Accepted: 04/26/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Computed tomography coronary angiography (CTCA) is an established modality for the diagnosis and assessment of cardiovascular disease. However, price and space pressure have mostly necessitated outsourcing CTCA to external radiology providers. Advara HeartCare has recently integrated CT services within local clinical networks across Australia. This study examined the benefits of the presence (integrated) or absence (pre-integrated) of this "in-house" CTCA service in real-world clinical practice. METHODS De-identified patient data from electronic medical records were used to create an Advara HeartCare CTCA database. Data analysis included clinical history, demographics, CTCA procedure, and 30-day outcomes post-CTCA from two age-matched cohorts: integrated (n = 495) and pre-integrated (n = 456). RESULTS Data capture was more comprehensive and standardised across the integrated cohort. There was a 21% increase in referrals for CTCA from cardiologists observed for the integration cohort vs. pre-integration [n = 332 (72.8%) pre-integration vs. n = 465 (93.9%) post-integration, p < 0.0001] with a parallel increase in diagnostic assessments including blood tests [n = 209 (45.8%) vs. n = 387 (78.1%), respectively, p < 0.0001]. The integrated cohort received lower total dose length product [Median 212 (interquartile range 136-418) mGy∗cm vs. 244 (141.5, 339.3) mGy∗cm, p = 0.004] during the CTCA procedure. 30-days after CTCA scan, there was a significantly higher use of lipid-lowering therapies in the integrated cohort [n = 133 (50.5%) vs. n = 179 (60.6%), p = 0.04], along with a significant decrease in the number of stress echocardiograms performed [n = 14 (10.6%) vs. n = 5 (11.6%), p = 0.01]. CONCLUSION Integrated CTCA has salient benefits in patient management, including increased pathology tests, statin usage, and decreased post-CTCA stress echocardiography utilisation. Our ongoing work will examine the effect of integration on cardiovascular outcomes.
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Affiliation(s)
- David Playford
- Advara HeartCare, 3/245 Given Terrace, Paddington, QLD, 4064, Australia; School of Medicine, The University of Notre Dame Australia, Fremantle, WA, Australia.
| | - Nisha Schwarz
- Advara HeartCare, 3/245 Given Terrace, Paddington, QLD, 4064, Australia
| | - Anna E Williamson
- Advara HeartCare, 3/245 Given Terrace, Paddington, QLD, 4064, Australia
| | - MyNgan Duong
- Advara HeartCare, 3/245 Given Terrace, Paddington, QLD, 4064, Australia
| | | | | | - Stuart Behncken
- Advara HeartCare, 3/245 Given Terrace, Paddington, QLD, 4064, Australia
| | - Tom Phillips
- Advara HeartCare, 3/245 Given Terrace, Paddington, QLD, 4064, Australia
| | - Leighton Kearney
- Advara HeartCare, 3/245 Given Terrace, Paddington, QLD, 4064, Australia; Department of Cardiology, Austin Health, Melbourne, VIC, Australia; Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
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7
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Meng J, Jiang H, Ren K, Zhou J. Comparison of risk assessment strategies incorporating coronary artery calcium score with estimation of pretest probability to defer cardiovascular testing in patients with stable chest pain. BMC Cardiovasc Disord 2023; 23:53. [PMID: 36709263 PMCID: PMC9884410 DOI: 10.1186/s12872-023-03076-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 01/17/2023] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The risk assessment of patients with stable chest pain (SCP) to defer further cardiovascular testing is crucial, but the most appropriate risk assessment strategy remains unknown. We aimed to compare current strategies to identify low risk SCP patients. METHODS 5289 symptomatic patients who had undergone coronary artery calcium score (CACS) and coronary computed tomographic angiography scan were identified and followed. Pretest probability (PTP) of obstructive coronary artery disease (CAD) for every patient was estimated according to European Society of Cardiology (ESC)-PTP model and CACS-weighted clinical likelihood (CACS-CL) model, respectively. Based on the 2019 ESC guideline-determined risk assessment strategy (ESC strategy) and CACS-CL model-based risk assessment strategy (CACS-CL strategy), all patients were divided into low and high risk group, respectively. Area under receiver operating characteristic curve (AUC), integrated discrimination improvement (IDI) and net reclassification improvement (NRI) was used. RESULTS CACS-CL model provided more robust estimation of PTP than ESC-PTP model did, with a larger AUC (0.838 versus 0.735, p < 0.0001), positive IDI (9%, p < 0.0001) and less discrepancy between observed and predicted probabilities. As a result, compared to ESC strategy which only applied CACS-CL model to patients with borderline ESC-PTP, CACS-CL strategy incorporating CACS with estimation of PTP to entire SCP patients indicated a positive NRI (19%, p < 0.0001) and a stronger association to major adverse cardiovascular events, with hazard ratios: 3.97 (95% confidence intervals: 2.75-5.72) versus 5.11 (95% confidence intervals: 3.40-7.69). CONCLUSION The additional use of CACS for all SCP patients in CACS-CL strategy improved the risk assessment of SCP patients to identify individuals at low risk.
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Affiliation(s)
- Jia Meng
- Department of Kidney Disease and Blood Purification, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Hantao Jiang
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Kai Ren
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Jia Zhou
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China.
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Jouni H, Gibbons RJ. Predictors of inducible ischemia with radionuclide stress testing: Choosing the right patients when the patients are changing. J Nucl Cardiol 2022; 29:2850-2852. [PMID: 34820769 DOI: 10.1007/s12350-021-02853-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 01/18/2023]
Affiliation(s)
- Hayan Jouni
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Raymond J Gibbons
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Rasmussen LD, Fordyce CB, Nissen L, Hill CL, Alhanti B, Hoffmann U, Udelson J, Bøttcher M, Douglas PS, Winther S. The PROMISE Minimal Risk Score Improves Risk Classification of Symptomatic Patients With Suspected CAD. JACC Cardiovasc Imaging 2022; 15:1442-1454. [DOI: 10.1016/j.jcmg.2022.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 03/15/2022] [Accepted: 03/17/2022] [Indexed: 12/11/2022]
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10
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Nanna MG, Vemulapalli S, Fordyce CB, Mark DB, Patel MR, Al-Khalidi HR, Kelsey M, Martinez B, Yow E, Mullen S, Stone GW, Ben-Yehuda O, Udelson JE, Rogers C, Douglas PS. The prospective randomized trial of the optimal evaluation of cardiac symptoms and revascularization: Rationale and design of the PRECISE trial. Am Heart J 2022; 245:136-148. [PMID: 34953768 PMCID: PMC8979644 DOI: 10.1016/j.ahj.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 12/14/2021] [Accepted: 12/14/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Clinicians vary widely in their preferred diagnostic approach to patients with non-acute chest pain. Such variation exposes patients to potentially avoidable risks, as well as inefficient care with increased costs and unresolved patient concerns. METHODS The Prospective Randomized Trial of the Optimal Evaluation of Cardiac Symptoms and Revascularization (PRECISE) trial (NCT03702244) compares an investigational "precision" diagnostic strategy to a usual care diagnostic strategy in participants with stable chest pain and suspected coronary artery disease (CAD). RESULTS PRECISE randomized 2103 participants with stable chest pain and a clinical recommendation for testing for suspected CAD at 68 outpatient international sites. The investigational precision evaluation strategy started with a pre-test risk assessment using the PROMISE Minimal Risk Tool. Those at lowest risk were assigned to deferred testing (no immediate testing), and the remainder received coronary computed tomographic angiography (cCTA) with selective fractional flow reserve (FFRCT) for any stenosis meeting a threshold of ≥30% and <90%. For participants randomized to usual care, the clinical care team selected the initial noninvasive or invasive test (diagnostic angiography) according to customary practice. The use of cCTA as the initial diagnostic strategy was proscribed by protocol for the usual care strategy. The primary endpoint is time to a composite of major adverse cardiac events (MACE: all-cause death or non-fatal myocardial infarction) or invasive cardiac catheterization without obstructive CAD at 1 year. Secondary endpoints include health care costs and quality of life. CONCLUSIONS PRECISE will determine whether a precision approach comprising a strategically deployed combination of risk-based deferred testing and cCTA with selective FFRCT improves the clinical outcomes and efficiency of the diagnostic evaluation of stable chest pain over usual care.
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Affiliation(s)
- Michael G. Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | | | - Christopher B. Fordyce
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Daniel B. Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Manesh R. Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Michelle Kelsey
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Beth Martinez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Eric Yow
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Gregg W. Stone
- Icahn School of Medicine at Mount Sinai, Mount Sinai Heart and the Cardiovascular Research Foundation, New York, NY
| | - Ori Ben-Yehuda
- Cardiovascular Research Foundation, NY, NY and the University of California, San Diego
| | - James E. Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA
| | | | - Pamela S. Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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11
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Zhao J, Wang S, Zhao P, Huo Y, Li C, Zhou J. Comparison of Risk Assessment Strategies for Patients with Diabetes Mellitus and Stable Chest Pain: A Coronary Computed Tomography Angiography Study. J Diabetes Res 2022; 2022:8183487. [PMID: 35127952 PMCID: PMC8808234 DOI: 10.1155/2022/8183487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/14/2021] [Accepted: 01/07/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND To compare two risk assessment strategies to identify individuals likely to benefit from further imaging testing in patients with diabetes mellitus (DM) and stable chest pain (SCP) suspected of obstructive coronary artery disease (CAD). METHODS 602 DM patients referred to coronary computed tomography angiography (CCTA) for SCP were included. They were divided into high- and low-risk groups according to the 2016 National Institute of Health and Care Excellence guideline-determined strategy (NICE strategy) which focused on symptom evaluation and 2019 European Society of Cardiology guideline-determined strategy (ESC strategy) which was based on pretest probability (PTP) sequentially determined by the ESC-PTP estimator and risk factor-weighted clinical likelihood (RF-CL) model, respectively. The associations of clinical outcomes with risk groups and net reclassification improvement (NRI) were evaluated. RESULTS The NICE and ESC strategy classified 44% and 39% patients into the low-risk group, respectively. Compared to the NICE strategy, the ESC strategy indicated stronger associations between risk groups and events (hazard ratios: 4.24 versus 1.91), intensive clinical management, and a positive NRI (27.71%, p < 0.0001). The application of the RF-CL model ameliorated the underestimation of risk in patients with borderline ESC-PTP, which principally account for the improvement of the ESC strategy. CONCLUSION Compared to the NICE strategy, the ESC strategy seemed to be associated with greater efficiency in identifying high risk individuals in patients with DM and SCP.
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Affiliation(s)
- Jia Zhao
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
- Graduate School, Tianjin Medical University, Tianjin, China
| | - Shuo Wang
- Graduate School, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Pengyu Zhao
- School of Electrical and Information Engineering, Tianjin University, Tianjin, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Chunjie Li
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Jia Zhou
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
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Zhou J, Li C, Cong H, Duan L, Wang H, Wang C, Tan Y, Liu Y, Zhang Y, Zhou X, Zhang H, Wang X, Ma Y, Yang J, Chen Y, Guo Z. Comparison of Different Investigation Strategies to Defer Cardiac Testing in Patients With Stable Chest Pain. JACC Cardiovasc Imaging 2021; 15:91-104. [PMID: 34656487 DOI: 10.1016/j.jcmg.2021.08.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 08/30/2021] [Accepted: 08/31/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVES This study aimed to compare the current 5 investigation strategies to defer cardiac testing in patients with stable chest pain. BACKGROUND For the clinical management of stable chest pain, the identification of patients unlikely to benefit from further cardiac testing is important, but the most appropriate investigation strategy is unknown. METHODS A total of 4,207 patients referred to coronary computed tomography angiography for stable chest pain were classified into low- and high-risk groups according to the 2016 National Institute of Health and Care Excellence (NICE) guideline-determined strategy; PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) minimal risk tool-based strategy; 2019 European Society of Cardiology (ESC) guideline-determined strategy; and coronary artery calcium score (CACS), either in isolation (the CACS strategy) or as part of a weighted clinical likelihood model-based strategy (the CACS-CL strategy). The associations of obstructive coronary artery disease on coronary computed tomography angiography, major adverse cardiovascular events, and subsequent clinical management with risk groups according to different strategies were evaluated and compared. RESULTS The NICE, PROMISE, ESC, CACS, and CACS-CL strategies classified a proportion (22.63%, 29.21%, 41.84%, 46.76%, and 51.41%, respectively) of patients into low-risk groups. Compared with the NICE, PROMISE, ESC, and CACS strategies, the CACS-CL strategy had a stronger association between risk groups and obstructive coronary artery disease (odd ratios: 16.00 vs 2.93, 5.53, 7.94, and 10.39, respectively), major adverse cardiovascular events (HRs: 6.83 vs 1.90, 2.94, 4.23, and 5.13, respectively) and intensive subsequent clinical management as well as better metrics of diagnostic accuracy and positive net reclassification improvement. CONCLUSIONS Among contemporary strategies used to identify patients with stable chest pain at low risk, the use of CACS, especially when combined with clinical risk features, showed the strongest potential to effectively defer cardiac testing.
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Affiliation(s)
- Jia Zhou
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China.
| | - Chunjie Li
- Department of Emergency, Tianjin Chest Hospital, Tianjin, China
| | - Hongliang Cong
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Lixiong Duan
- Graduate School of Tianjin Medical University, Tianjin, China
| | - Hao Wang
- National Center for Clinical Medical Research of Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Chengjian Wang
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Yahang Tan
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yujie Liu
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Ying Zhang
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Xiujun Zhou
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Hong Zhang
- Department of Radiology, Tianjin Chest Hospital, Tianjin, China
| | - Xing Wang
- Department of Radiology, Tianjin Chest Hospital, Tianjin, China
| | - Yanhe Ma
- Department of Radiology, Tianjin Chest Hospital, Tianjin, China
| | - Junjie Yang
- Department of Cardiology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yundai Chen
- Department of Cardiology, Chinese People's Liberation Army General Hospital, Beijing, China.
| | - Zhigang Guo
- Department of Cardiovascular Surgery, Tianjin Chest Hospital, Tianjin, China.
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Nanna MG, Wang TY, Chiswell K, Sun JL, Vemulapalli S, Hoffmann U, Patel MR, Udelson JE, Fordyce CB, Douglas PS. Estimating the real-world performance of the PROMISE minimal-risk tool. Am Heart J 2021; 239:100-109. [PMID: 34077743 DOI: 10.1016/j.ahj.2021.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 05/25/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Stable chest pain is a common indication for cardiac catheterization. We assessed the prognostic value of the Prospective Multicenter Imaging Study for Evaluation (PROMISE) Minimal-Risk Tool in identifying patients who are at very low risk of obstructive coronary artery disease (CAD) or downstream cardiovascular adverse outcomes. METHODS We applied the PROMISE Minimal-Risk Tool to consecutive patients without known CAD who underwent elective cardiac catheterization for stable angina from January 1, 2000 to December 31, 2014 in the Duke Databank for Cardiovascular Disease (DDCD). Patients with scores >0.46 (top decile of lowest-risk from the PROMISE cohort) were classified as low-risk. Logistic regression modeling compared likelihood of freedom from obstructive coronary artery disease on index angiography, 2-year survival, and 2-year survival free of myocardial infarction (MI) and MI/revascularization between low- and non low-risk patients. Alternative cut points to define low- risk patients were also explored. RESULTS Among 6251 patients undergoing cardiac catheterization for stable chest pain, 1082 (17.3%) were low-risk per the PROMISE minimal-risk tool. Among low risk patients, obstructive coronary artery disease was observed in 14.9% and left main disease (≥ 50% Stenosis) was rare (0.9%). Compared with other patients, low risk patients had a higher likelihood of freedom from obstructive coronary disease on index catheterization (85.1% vs. 44.2%, OR 4.84, 95% CI 4.06-5.77). Low risk patients had significantly higher survival (98.2% vs. 94.4%, OR 3.18, 95% CI 1.99-5.08), MI-free survival (97.2% vs. 91.9%, OR 3.03, 95% CI 2.07-4.45), and MI/revascularization-free survival (86.2 vs. 59.9%, OR 4.19, 95% CI 3.48-5.05) at 2 years than non-low risk patients. Operating characteristics for predicting the outcomes of interest varied modestly depending on the low-risk cut-point used but the positive predictive value for 2 year freedom from death was >98% regardless. CONCLUSION The PROMISE minimal-risk tool identifies 17% of stable chest pain patients referred to cardiac catheterization as low risk. These patients have a low prevalence of obstructive CAD and better survival than non-low risk patients. While this suggests that these patients are unlikely to benefit from catheterization, further research is needed to confirm a favorable downstream prognosis with medical management alone.
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Analysis of clinical risk models vs. clinician's assessment for prediction of coronary artery disease among predominantly female population. Coron Artery Dis 2021; 33:182-188. [PMID: 34380955 DOI: 10.1097/mca.0000000000001090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Multiple risk models are used to predict the presence of obstructive coronary artery disease (CAD) in patients with chest pain. We aimed to compare the performance of these models to an experienced cardiologist's assessment utilizing coronary angiography (CA) as a reference. MATERIALS AND METHODS We prospectively enrolled patients without known CAD referred for elective CA. We assessed pretest probability of CAD using the following risk models: Diamond-Forrester (original and updated), Duke Clinical score, ACC/AHA, CAD consortium (basic and clinical) and PROMISE minimal risk tool. All patients completed self-administrative Rose angina questionnaire. Independently, an experienced cardiologist assessed the patients to provide a binary prediction of obstructive CAD prior to CA. Obstructive CAD was defined as >80% stenosis in epicardial coronary arteries by visual assessment, or fractional flow reserve <0.80 in intermediate lesions (30-80%). RESULTS A total of 150 patients were recruited (100 women, 50 men). Mean age was 58 (32-78) years. Obstructive CAD was found in 31 patients (21%). The area under the curve (AUC) for all the clinical risk prediction models (except the Duke Clinical Score, AUC 0.73, P = 0.07) was significantly lower compared with the clinician's assessment (AUC 0.51-0.65 vs. 0.81, respectively, P < 0.01). The clinician's assessment had sensitivity comparable to the Duke Clinical score, which was higher than all other clinical models. There was no difference in prediction performance on the basis of sex in this predominantly female population. DISCUSSION/CONCLUSION In stable patients with chest pain and suspected CAD, current clinical risk models which are universally based upon the characteristics of the chest pain, show suboptimal performance in predicting obstructive CAD. These findings have important clinical implications, as current appropriateness criteria for recommending CA are on the basis of these risk models.
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15
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Bodini A, Michelucci E, Di Giorgi N, Caselli C, Signore G, Neglia D, Smit JM, Scholte AJHA, Mincarone P, Leo CG, Pelosi G, Rocchiccioli S. Predictive Added Value of Selected Plasma Lipids to a Re-estimated Minimal Risk Tool. Front Cardiovasc Med 2021; 8:682785. [PMID: 34336947 PMCID: PMC8322727 DOI: 10.3389/fcvm.2021.682785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/10/2021] [Indexed: 01/13/2023] Open
Abstract
Background: Lipidomics is emerging for biomarker discovery in cardiovascular disease, and circulating lipids are increasingly incorporated in risk models to predict cardiovascular events. Moreover, specific classes of lipids, such as sphingomyelins, ceramides, and triglycerides, have been related to coronary artery disease (CAD) severity and plaque characteristics. To avoid unnecessary testing, it is important to identify individuals at low CAD risk. The only pretest model available so far to rule out the presence of coronary atherosclerosis in patients with chest pain, but normal coronary arteries, is the minimal risk tool (MRT). Aim: Using state-of-the-art statistical methods, we aim to verify the additive predictive value of a set of lipids, derived from targeted plasma lipidomics of suspected CAD patients, to a re-estimated version of the MRT for ruling out the presence of coronary atherosclerosis assessed by coronary CT angiography (CCTA). Methods: Two hundred and fifty-six subjects with suspected stable CAD recruited from five European countries within H2020-SMARTool, undergoing CCTA and blood sampling for clinical biochemistry and lipidomics, were selected. The MRT was validated by regression methods and then re-estimated (reMRT). The reMRT was used as a baseline model in a likelihood ratio test approach to assess the added predictive value of each lipid from 13 among ceramides, triglycerides, and sphingomyelins. Except for one lipid, the analysis was carried out on more than 240 subjects for each lipid. A sensitivity analysis was carried out by considering two alternative models developed on the cohort as baseline models. Results: In 205 subjects, coronary atherosclerosis ranged from minimal lesions to overt obstructive CAD, while in 51 subjects (19.9%) the coronary arteries were intact. Four triglycerides and seven sphingomyelins were significantly (p < 0.05) and differentially expressed in the two groups and, at a lesser extent, one ceramide (p = 0.067). The probability of being at minimal risk was significantly better estimated by adding either Cer(d18:1/16:0) (p = 0.01), SM(40:2) (p = 0.04), or SM(41:1) at a lesser extent (p = 0.052) to reMRT than by applying the reMRT alone. The sensitivity analysis confirmed the relevance of these lipids. Furthermore, the addition of SM(34:1), SM(38:2), SM(41:2), and SM(42:4) improved the predictive performance of at least one of the other baseline models. None of the selected triglycerides was found to provide an added value. Conclusions: Plasma lipidomics can be a promising source of diagnostic and prognostic biomarkers in cardiovascular disease, exploitable not only to assess the risk of adverse events but also to identify subjects without coronary atherosclerosis, thus reducing unnecessary further testing in normal subjects.
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Affiliation(s)
- Antonella Bodini
- Institute for Applied Mathematics and Information Technologies "E. Magenes," National Research Council, Milan, Italy
| | - Elena Michelucci
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | | | - Chiara Caselli
- Institute of Clinical Physiology, National Research Council, Pisa, Italy.,Cardiovascular Department, Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Giovanni Signore
- NEST, Scuola Normale Superiore, Pisa, Italy.,Fondazione Pisana per la Scienza, San Giuliano Terme, Italy
| | - Danilo Neglia
- Cardiovascular Department, Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Jeff M Smit
- Department of Cardiology, Leiden University Medical Centre, Leiden, Netherlands
| | | | - Pierpaolo Mincarone
- Institute for Research on Population and Social Policies, National Research Council, Brindisi, Italy
| | - Carlo G Leo
- Institute of Clinical Physiology, National Research Council, Lecce, Italy
| | - Gualtiero Pelosi
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
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Mincarone P, Bodini A, Tumolo MR, Vozzi F, Rocchiccioli S, Pelosi G, Caselli C, Sabina S, Leo CG. Discrimination capability of pretest probability of stable coronary artery disease: a systematic review and meta-analysis suggesting how to improve validation procedures. BMJ Open 2021; 11:e047677. [PMID: 34244268 PMCID: PMC8268916 DOI: 10.1136/bmjopen-2020-047677] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Externally validated pretest probability models for risk stratification of subjects with chest pain and suspected stable coronary artery disease (CAD), determined through invasive coronary angiography or coronary CT angiography, are analysed to characterise the best validation procedures in terms of discriminatory ability, predictive variables and method completeness. DESIGN Systematic review and meta-analysis. DATA SOURCES Global Health (Ovid), Healthstar (Ovid) and MEDLINE (Ovid) searched on 22 April 2020. ELIGIBILITY CRITERIA We included studies validating pretest models for the first-line assessment of patients with chest pain and suspected stable CAD. Reasons for exclusion: acute coronary syndrome, unstable chest pain, a history of myocardial infarction or previous revascularisation; models referring to diagnostic procedures different from the usual practices of the first-line assessment; univariable models; lack of quantitative discrimination capability. METHODS Eligibility screening and review were performed independently by all the authors. Disagreements were resolved by consensus among all the authors. The quality assessment of studies conforms to the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2). A random effects meta-analysis of area under the receiver operating characteristic curve (AUC) values for each validated model was performed. RESULTS 27 studies were included for a total of 15 models. Besides age, sex and symptom typicality, other risk factors are smoking, hypertension, diabetes mellitus and dyslipidaemia. Only one model considers genetic profile. AUC values range from 0.51 to 0.81. Significant heterogeneity (p<0.003) was found in all but two cases (p>0.12). Values of I2 >90% for most analyses and not significant meta-regression results undermined relevant interpretations. A detailed discussion of individual results was then carried out. CONCLUSIONS We recommend a clearer statement of endpoints, their consistent measurement both in the derivation and validation phases, more comprehensive validation analyses and the enhancement of threshold validations to assess the effects of pretest models on clinical management. PROSPERO REGISTRATION NUMBER CRD42019139388.
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Affiliation(s)
- Pierpaolo Mincarone
- Institute for Research on Population and Social Policies, National Research Council, Brindisi, Italy
| | - Antonella Bodini
- Institute for Applied Mathematics and Information Technologies "Enrico Magenes", National Research Council, Milan, Italy
| | - Maria Rosaria Tumolo
- Institute for Research on Population and Social Policies, National Research Council, Brindisi, Italy
| | - Federico Vozzi
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | | | - Gualtiero Pelosi
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Chiara Caselli
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Saverio Sabina
- Institute of Clinical Physiology, National Research Council, Lecce, Italy
| | - Carlo Giacomo Leo
- Institute of Clinical Physiology, National Research Council, Lecce, Italy
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Newby DE, Adamson PD, Shaw LJ. Consistency and Generalizability of Trials for Coronary Computed Tomography Angiography. JAMA Cardiol 2021; 6:483-484. [PMID: 33355616 DOI: 10.1001/jamacardio.2020.6124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Affiliation(s)
- David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
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Murthy VL, Nasir K. Staged testing as a solution to the challenges of testing lower risk patients. J Nucl Cardiol 2020; 27:1497-1500. [PMID: 30225816 PMCID: PMC6421111 DOI: 10.1007/s12350-018-1437-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 01/09/2023]
Affiliation(s)
- Venkatesh L Murthy
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, 1500 E. Medical Center Dr, SPC 5873, Ann Arbor, MI, 48109-5873, USA.
| | - Khurram Nasir
- Division of Cardiovascular Medicine, Center for Outcomes & Research Evaluation (CORE), Yale University School of Medicine & Yale New Haven Health, New Haven, CT, USA
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Bing R, Singh T, Dweck MR, Mills NL, Williams MC, Adamson PD, Newby DE. Validation of European Society of Cardiology pre-test probabilities for obstructive coronary artery disease in suspected stable angina. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2020; 6:293-300. [PMID: 31977010 PMCID: PMC7590886 DOI: 10.1093/ehjqcco/qcaa006] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 01/13/2020] [Accepted: 01/16/2020] [Indexed: 01/25/2023]
Abstract
AIMS To assess contemporary pre-test probability estimates for obstructive coronary artery disease in patients with stable chest pain. METHODS AND RESULTS In this substudy of a multicentre randomized controlled trial, we compared 2019 European Society of Cardiology (ESC)-endorsed pre-test probabilities with observed prevalence of obstructive coronary artery disease on computed tomography coronary angiography (CTCA). We assessed associations between pre-test probability, 5-year coronary heart disease death or non-fatal myocardial infarction and study intervention (standard care vs. CTCA). The study population consisted of 3755 patients (30-75 years, 46% women) with a median pre-test probability of 11% of whom 1622 (43%) had a pre-test probability of >15%. In those who underwent CTCA (n = 1613), the prevalence of obstructive disease was 22%. When divided into deciles of pre-test probability, the observed disease prevalence was similar but higher than the corresponding median pre-test probability [median difference 2.3 (1.3-5.6)%]. There were more clinical events in patients with a pre-test probability >15% compared to those at 5-15% and <5% (4.1%, 1.5%, and 1.4%, respectively, P < 0.001). Across the total cohort, fewer clinical events occurred in patients who underwent CTCA, with the greatest difference in those with a pre-test probability >15% (2.8% vs. 5.3%, log rank P = 0.01), although this interaction was not statistically significant on multivariable modelling. CONCLUSION The updated 2019 ESC guideline pre-test probability recommendations tended to slightly underestimate disease prevalence in our cohort. Pre-test probability is a powerful predictor of future coronary events and helps select those who may derive the greatest absolute benefit from CTCA.
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Affiliation(s)
- Rong Bing
- BHF Centre for Cardiovascular Science, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
| | - Trisha Singh
- BHF Centre for Cardiovascular Science, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
| | - Marc R Dweck
- BHF Centre for Cardiovascular Science, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, 9 Little France Road, Edinburgh EH16 4UX, UK
| | - Michelle C Williams
- BHF Centre for Cardiovascular Science, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
| | - Philip D Adamson
- BHF Centre for Cardiovascular Science, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
- Christchurch Heart Institute, University of Otago, 2 Riccarton Avenue, Christchurch 8011, New Zealand
| | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
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Validation and update of the minimal risk tool in patients suspected of chronic coronary syndrome. Int J Cardiovasc Imaging 2020; 37:699-706. [PMID: 32875484 DOI: 10.1007/s10554-020-01982-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/24/2020] [Indexed: 01/03/2023]
Abstract
Risk stratification in patients with suspected coronary artery disease (CAD) is important. Recently, the minimal-risk-tool (MRT) was developed to identify individuals with low CAD risk despite symptoms in order to avoid unnecessary testing. We aimed to validate and update the MRT-model in a contemporary cohort. The Dan-NICAD trial cohort, consisting of 1675 consecutive patients referred for coronary computed tomography angiography (CTA), was used to calculate the MRT-score based on the published fitted variable coefficients from the PROMISE and SCOT-HEART trials. Minimal risk was defined as zero calcium score, no coronary atherosclerosis at coronary CTA, and no cardiovascular events in the follow-up period. We tested an updated MRT-model by pooling the fitted variable coefficients from all three trials. A total of 1544 patients fulfilling the inclusion criteria were followed for 3.1 [2.7-3.4] years. In 710 (46%) patients, the criteria for minimal risk were fulfilled. Despite substantial coefficient variation, the MRTs based on the PROMISE, the SCOT-HEART and the updated MRT variables showed similar moderate to high discriminative performance for minimal risk estimation. Although all three models tended to underestimate minimal risk, the updated MRT had the best performance. Using a 75% minimal risk cut-off, the updated MRT showed a sensitivity of 11.6% (95% CI 9.3-14.2%) and specificity of 99.3% (95% CI 98.6-99.8%). An updated MRT model based on three large studies increased calibration compared to the existing MRT models, whereas discrimination was similar despite substantial coefficient variation. The updated MRT might supplement currently recommended pre-test probability models.
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21
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Singh T, Bing R, Dweck MR, van Beek EJR, Mills NL, Williams MC, Villines TC, Newby DE, Adamson PD. Exercise Electrocardiography and Computed Tomography Coronary Angiography for Patients With Suspected Stable Angina Pectoris: A Post Hoc Analysis of the Randomized SCOT-HEART Trial. JAMA Cardiol 2020; 5:920-928. [PMID: 32492104 PMCID: PMC7271417 DOI: 10.1001/jamacardio.2020.1567] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 03/13/2020] [Indexed: 12/13/2022]
Abstract
Importance Recent European guidance supports a diminished role for exercise electrocardiography (ECG) in the assessment of suspected stable angina. Objective To evaluate the utility of exercise ECG in contemporary practice and assess the value of combined functional and anatomical testing. Design, Setting, and Participants This is a post hoc analysis of the Scottish Computed Tomography of the Heart (SCOT-HEART) open-label randomized clinical trial, conducted in 12 cardiology chest pain clinics across Scotland for patients with suspected angina secondary to coronary heart disease. Between November 18, 2010, and September 24, 2014, 4146 patients aged 18 to 75 years with stable angina underwent clinical evaluation and 1417 of 1651 (86%) underwent exercise ECG prior to randomization. Statistical analysis was conducted from October 10 to November 5, 2019. Interventions Patients were randomized in a 1:1 ratio to receive standard care plus coronary computed tomography (CT) angiography or to receive standard care alone. The present analysis was limited to the 3283 patients who underwent exercise ECG alone or in combination with coronary CT angiography. Main Outcomes and Measures The primary clinical end point was death from coronary heart disease or nonfatal myocardial infarction at 5 years. Results Among the 3283 patients (1889 men; median age, 57.0 years [interquartile range, 50.0-64.0 years]), exercise ECG had a sensitivity of 39% and a specificity of 91% for detecting any obstructive coronary artery disease in those who underwent subsequent invasive angiography. Abnormal results of exercise ECG were associated with a 14.47-fold (95% CI, 10.00-20.41; P < .001) increase in coronary revascularization at 1 year and a 2.57-fold (95% CI, 1.38-4.63; P < .001) increase in mortality from coronary heart disease death at 5 years or in cases of nonfatal myocardial infarction at 5 years. Compared with exercise ECG alone, results of coronary CT angiography had a stronger association with 5-year coronary heart disease death or nonfatal myocardial infarction (hazard ratio, 10.63; 95% CI, 2.32-48.70; P = .002). The greatest numerical difference in outcome with CT angiography compared with exercise ECG alone was observed for those with inconclusive results of exercise ECG (5 of 285 [2%] vs 13 of 283 [5%]), although this was not statistically significant (log-rank P = .05). Conclusions and Relevance This study suggests that abnormal results of exercise ECG are associated with coronary revascularization and the future risk of adverse coronary events. However, coronary CT angiography more accurately detects coronary artery disease and is more strongly associated with future risk compared with exercise ECG. Trial Registration ClinicalTrials.gov Identifier: NCT01149590.
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Affiliation(s)
- Trisha Singh
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Rong Bing
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Marc R. Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Edwin J. R. van Beek
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Nicholas L. Mills
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Michelle C. Williams
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Todd C. Villines
- Division of Cardiovascular Medicine, University of Virginia, Charlottesville
| | - David E. Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Philip D. Adamson
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
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22
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Affiliation(s)
- Neel M Butala
- Division of Cardiology Massachusetts General Hospital Boston MA USA.,Harvard Medical School Boston MA USA
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23
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Impact of sex-specific differences in calculating the pretest probability of obstructive coronary artery disease in symptomatic patients: a coronary computed tomographic angiography study. Coron Artery Dis 2020; 30:124-130. [PMID: 30629000 PMCID: PMC6369895 DOI: 10.1097/mca.0000000000000696] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Objectives Little is known about the impact of sex-specific differences in calculating the pretest probability (PTP) of obstructive coronary artery disease. We sought to determine whether the calculation of PTP differ by sex in symptomatic patients referred to coronary computed tomographic angiography (CCTA). Patients and methods The characteristics of 5777 men and women who underwent CCTA were compared. For each patient, PTP was calculated according to the updated Diamond–Forrester method (UDFM) and the Duke clinical score (DCS), respectively. Follow-up clinical data were also recorded. Area under the receiver operating characteristic curve, integrated discrimination improvement, net reclassification improvement, and the Hosmer–Lemeshow goodness-of-fit statistic were used to assess the models’ performance. Results The area under the receiver operating characteristic curve of UDFM and DCS showed little difference in men (0.782 vs. 0.785, P=0.4708) and women (0.668 vs. 0.654, P=0.1255), and calibration of neither model was satisfactory. Compared with UDFM, DCS showed positive integrated discrimination improvement (10% in men, P<0.0001, and 8% in women, P<0.0001, respectively), net reclassification improvement (12.17% in men, P<0.0001, and 27.19% in women, P<0.0001, respectively), and obviously reduced unnecessary noninvasive testing for women with negative CCTA. Conclusion Although the performance of neither model was favorable, DCS offered a more accurate calculation of PTP than UDFM and application of DCS instead of UDFM would result in a significant decrease in inappropriate testing, especially in women.
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Recht MP, Dewey M, Dreyer K, Langlotz C, Niessen W, Prainsack B, Smith JJ. Integrating artificial intelligence into the clinical practice of radiology: challenges and recommendations. Eur Radiol 2020; 30:3576-3584. [PMID: 32064565 DOI: 10.1007/s00330-020-06672-5] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/21/2019] [Accepted: 01/23/2020] [Indexed: 12/31/2022]
Abstract
Artificial intelligence (AI) has the potential to significantly disrupt the way radiology will be practiced in the near future, but several issues need to be resolved before AI can be widely implemented in daily practice. These include the role of the different stakeholders in the development of AI for imaging, the ethical development and use of AI in healthcare, the appropriate validation of each developed AI algorithm, the development of effective data sharing mechanisms, regulatory hurdles for the clearance of AI algorithms, and the development of AI educational resources for both practicing radiologists and radiology trainees. This paper details these issues and presents possible solutions based on discussions held at the 2019 meeting of the International Society for Strategic Studies in Radiology. KEY POINTS: • Radiologists should be aware of the different types of bias commonly encountered in AI studies, and understand their possible effects. • Methods for effective data sharing to train, validate, and test AI algorithms need to be developed. • It is essential for all radiologists to gain an understanding of the basic principles, potentials, and limits of AI.
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Affiliation(s)
- Michael P Recht
- Department of Radiology, New York University Robert I Grossman School of Medicine, New York, NY, USA.
| | - Marc Dewey
- Charité - Universitätsmedizin Berlin, Humboldt-Universität and Freie Universität zu Berlin, Berlin, Germany
| | - Keith Dreyer
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Curtis Langlotz
- Department of Radiology and Biomedical Informatics, Stanford University, Palo Alto, CA, USA
| | - Wiro Niessen
- Department of Radiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Faculty of Applied Sciences, Delft University of Technology, Delft, The Netherlands
| | - Barbara Prainsack
- Department of Political Science, University of Vienna, Vienna, Austria
- Department of Global Health & Social Medicine, King's College, London, UK
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Adamson PD, Williams MC, Dweck MR, Mills NL, Boon NA, Daghem M, Bing R, Moss AJ, Mangion K, Flather M, Forbes J, Hunter A, Norrie J, Shah ASV, Timmis AD, van Beek EJR, Ahmadi AA, Leipsic J, Narula J, Newby DE, Roditi G, McAllister DA, Berry C. Guiding Therapy by Coronary CT Angiography Improves Outcomes in Patients With Stable Chest Pain. J Am Coll Cardiol 2019; 74:2058-2070. [PMID: 31623764 PMCID: PMC6899446 DOI: 10.1016/j.jacc.2019.07.085] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/23/2019] [Accepted: 07/28/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Within the SCOT-HEART (Scottish COmputed Tomography of the HEART Trial) trial of patients with stable chest pain, the use of coronary computed tomography angiography (CTA) reduced the rate of death from coronary heart disease or nonfatal myocardial infarction (primary endpoint). OBJECTIVES This study sought to assess the consistency and mechanisms of the 5-year reduction in this endpoint. METHODS In this open-label trial, 4,146 participants were randomized to standard care alone or standard care plus coronary CTA. This study explored the primary endpoint by symptoms, diagnosis, coronary revascularizations, and preventative therapies. RESULTS Event reductions were consistent across symptom and risk categories (p = NS for interactions). In patients who were not diagnosed with angina due to coronary heart disease, coronary CTA was associated with a lower primary endpoint incidence rate (0.23; 95% confidence interval [CI]: 0.13 to 0.35 vs. 0.59; 95% CI: 0.42 to 0.80 per 100 patient-years; p < 0.001). In those who had undergone coronary CTA, rates of coronary revascularization were higher in the first year (hazard ratio [HR]: 1.21; 95% CI: 1.01 to 1.46; p = 0.042) but lower beyond 1 year (HR: 0.59; 95% CI: 0.38 to 0.90; p = 0.015). Patients assigned to coronary CTA had higher rates of preventative therapies throughout follow-up (p < 0.001 for all), with rates highest in those with CT-defined coronary artery disease. Modeling studies demonstrated the plausibility of the observed effect size. CONCLUSIONS The beneficial effect of coronary CTA on outcomes is consistent across subgroups with plausible underlying mechanisms. Coronary CTA improves coronary heart disease outcomes by enabling better targeting of preventative treatments to those with coronary artery disease. (Scottish COmputed Tomography of the HEART Trial [SCOT-HEART]; NCT01149590).
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Affiliation(s)
- Philip D Adamson
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Christchurch Heart Institute, University of Otago, Christchurch, New Zealand.
| | - Michelle C Williams
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute University of Edinburgh, Edinburgh, United Kingdom
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute University of Edinburgh, Edinburgh, United Kingdom
| | - Nicholas L Mills
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute University of Edinburgh, Edinburgh, United Kingdom
| | - Nicholas A Boon
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Marwa Daghem
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute University of Edinburgh, Edinburgh, United Kingdom
| | - Rong Bing
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute University of Edinburgh, Edinburgh, United Kingdom
| | - Alastair J Moss
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute University of Edinburgh, Edinburgh, United Kingdom
| | - Kenneth Mangion
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - John Forbes
- Health Research Institute, University of Limerick, Limerick, Ireland
| | - Amanda Hunter
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute University of Edinburgh, Edinburgh, United Kingdom
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, United Kingdom
| | - Anoop S V Shah
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute University of Edinburgh, Edinburgh, United Kingdom
| | - Adam D Timmis
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Edwin J R van Beek
- Edinburgh Imaging, Queen's Medical Research Institute University of Edinburgh, Edinburgh, United Kingdom
| | - Amir A Ahmadi
- Ichan School of Medicine and Mount Sinai Hospital, Mount Sinai Heart, New York, New York; St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jonathon Leipsic
- St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jagat Narula
- Ichan School of Medicine and Mount Sinai Hospital, Mount Sinai Heart, New York, New York
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute University of Edinburgh, Edinburgh, United Kingdom
| | - Giles Roditi
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - David A McAllister
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
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Baskaran L, Danad I, Gransar H, Ó Hartaigh B, Schulman-Marcus J, Lin FY, Peña JM, Hunter A, Newby DE, Adamson PD, Min JK. A Comparison of the Updated Diamond-Forrester, CAD Consortium, and CONFIRM History-Based Risk Scores for Predicting Obstructive Coronary Artery Disease in Patients With Stable Chest Pain. JACC Cardiovasc Imaging 2019; 12:1392-1400. [DOI: 10.1016/j.jcmg.2018.02.020] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 02/22/2018] [Accepted: 02/23/2018] [Indexed: 01/21/2023]
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Adamson PD, Newby DE, Hill CL, Coles A, Douglas PS, Fordyce CB. Comparison of International Guidelines for Assessment of Suspected Stable Angina: Insights From the PROMISE and SCOT-HEART. JACC Cardiovasc Imaging 2018; 11:1301-1310. [PMID: 30190030 PMCID: PMC6130226 DOI: 10.1016/j.jcmg.2018.06.021] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 06/29/2018] [Indexed: 01/06/2023]
Abstract
OBJECTIVES This study sought to compare the performance of major guidelines for the assessment of stable chest pain including risk-based (American College of Cardiology/American Heart Association and European Society of Cardiology) and symptom-focused (National Institute for Health and Care Excellence) strategies. BACKGROUND Although noninvasive testing is not recommended in low-risk individuals with stable chest pain, guidelines recommend differing approaches to defining low-risk patients. METHODS Patient-level data were obtained from the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) and SCOT-HEART (Scottish Computed Tomography of the Heart) trials. Pre-test probability was determined and patients dichotomized into low-risk and intermediate-high-risk groups according to each guideline's definitions. The primary endpoint was obstructive coronary artery disease on coronary computed tomography angiography. Secondary endpoints were coronary revascularization at 90 days and cardiovascular death or nonfatal myocardial infarction up to 3 years. RESULTS In total, 13,773 patients were included of whom 6,160 had coronary computed tomography angiography. The proportions of patients identified as low risk by the American College of Cardiology/American Heart Association, European Society of Cardiology, and National Institute for Health and Care Excellence guidelines, respectively, were 2.5%, 2.5%, and 10.0% within PROMISE, and 14.0%, 19.8%, and 38.4% within SCOT-HEART. All guidelines identified lower rates of obstructive coronary artery disease in low- versus intermediate-high-risk patients with a negative predictive value of ≥0.90. Compared with low-risk groups, all intermediate-high-risk groups had greater risks of coronary revascularization (odds ratio [OR]: 2.2 to 24.1) and clinical outcomes (OR: 1.84 to 5.8). CONCLUSIONS Compared with risk-based guidelines, symptom-focused assessment identifies a larger group of low-risk chest pain patients potentially deriving limited benefit from noninvasive testing. (Scottish Computed Tomography of the Heart Trial [SCOT-HEART]; NCT01149590; Prospective Multicenter Imaging Study for Evaluation of Chest Pain [PROMISE]; NCT01174550).
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Affiliation(s)
- Philip D Adamson
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - C Larry Hill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Adrian Coles
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Christopher B Fordyce
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
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