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Fordyce CB, Hill CL, Mark DB, Alhanti B, Pellikka PA, Hoffmann U, Patel MR, Douglas PS. Physician judgement in predicting obstructive coronary artery disease and adverse events in chest pain patients. Heart 2022; 108:860-867. [PMID: 35110385 PMCID: PMC9106875 DOI: 10.1136/heartjnl-2021-320275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/20/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To evaluate informal physician judgement versus pretest probability scores in estimating risk in patients with suspected coronary artery disease (CAD). METHODS We included 4533 patients from the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial. Physicians categorised a priori the pretest probability of obstructive CAD (≥70% or ≥50% left main); Diamond-Forrester (D-F) and European Society of Cardiology (ESC) pretest probability estimates were calculated. Agreement was calculated using the κ statistic; logistic regression evaluated estimates of pretest CAD probability and actual CAD (as determined by CT coronary angiography), and clinical outcomes were modelled using Cox proportional hazard models. RESULTS Physician estimates agreed poorly with D-F (κ 0.16; 95% CI 0.14 to 0.18) and ESC (κ 0.04; 95% CI 0.02 to 0.05). Actual obstructive CAD was significantly more prevalent in both the high-likelihood (OR 3.30; 95% CI 2.30 to 4.74) and the intermediate-likelihood (OR 1.43; 95% CI 1.16 to 1.76) physician-estimated groups versus the low-likelihood group; ESC similarly differentiated between the three groups (OR 9.07; 95% CI 2.87 to 28.70; and OR 3.87; 95% CI 1.22 to 12.28). However, using D-F, only the high-probability group differed (OR 2.49; 95% CI 1.74 to 3.54). Only physician estimates were associated with a higher incidence of adjusted death/myocardial infarction/unstable angina hospitalisation in the high-probability versus low-probability group (HR 2.68; 95% CI 1.52 to 4.74); neither pretest probability score provided prognostic information. CONCLUSIONS Compared with D-F and ESC estimates, physician judgement more accurately identified obstructive CAD and worse patient outcomes. Integrating physician judgement may improve risk prediction for patients with stable chest pain. TRIAL REGISTRATION NUMBER NCT01174550.
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Affiliation(s)
- Christopher B Fordyce
- Division of Cardiology and Centre for Cardiovascular Innovation, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - C Larry Hill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Brooke Alhanti
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Udo Hoffmann
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
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2
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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: 1] [Impact Index Per Article: 0.3] [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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3
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Espersen C, Modin D, Hoffmann S, Hagemann CA, Hagemann RA, Olsen FJ, Fritz-Hansen T, Platz E, Møgelvang R, Biering-Sørensen T. Layer-specific and whole wall global longitudinal strain predict major adverse cardiovascular events in patients with stable angina pectoris. Int J Cardiovasc Imaging 2021; 38:131-140. [PMID: 34415451 DOI: 10.1007/s10554-021-02382-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
Global longitudinal strain (GLS) has proven to be a powerful prognostic marker in various patient populations, but the prognostic value of layer-specific GLS has not yet been investigated in patients with suspected stable angina pectoris (SAP). We sought to investigate the prognostic value of layer-specific and whole wall GLS in patients with suspected SAP. From September 2008 to March 2011, 296 consecutive patients with clinically suspected SAP, normal ejection fraction, and no previous cardiac history were enrolled in a prospective cohort study. Patients underwent echocardiography including two-dimensional speckle tracking at rest, exercise stress test, and coronary angiography. The end-point was a composite of incident heart failure, acute myocardial infarction, and cardiovascular death (MACE). Out of the 285 included patients (mean age 61 years, 50% male), 24 (8%) developed MACE during a median follow-up of 3.5 years. Both endocardial [hazard ratio (HR) 1.21, 95% CI 1.08-1.35, p = 0.001], epicardial (HR 1.29, 95% CI 1.12-1.50, p = 0.001) and whole wall GLS (HR 1.25, 1.10-1.42, p = 0.001) were significantly associated with an increased risk of developing MACE during follow-up in univariable Cox regression analysis. In multivariable analysis, only epicardial (HR 1.23, 95% CI 1.00-1.51, p = 0.046) and whole wall GLS (HR 1.20, 95% CI 1.00-1.43, p = 0.049) remained significantly associated with an increased risk of MACE independent of various baseline clinical variables, left ventricular ejection fraction (LVEF), E/e' and Duke Score. Layer-specific and whole wall GLS were significant predictors of MACE in this cohort of patients with suspected SAP independent of various baseline clinical variables, LVEF, E/e' and Duke Score.
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Affiliation(s)
- Caroline Espersen
- Cardiovascular Non-Invasive Imaging Research Laboratory, Department of Cardiology, Herlev & Gentofte Hospital, Copenhagen, Denmark.
| | - Daniel Modin
- Cardiovascular Non-Invasive Imaging Research Laboratory, Department of Cardiology, Herlev & Gentofte Hospital, Copenhagen, Denmark
| | - Søren Hoffmann
- Department of Anesthesiology and Intensive Care Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - Christoffer A Hagemann
- Center for Clinical Metabolic Research, Herlev & Gentofte Hospital, Copenhagen, Denmark.,Gubra Aps, Hørsholm, Denmark
| | - Rikke A Hagemann
- Cardiovascular Non-Invasive Imaging Research Laboratory, Department of Cardiology, Herlev & Gentofte Hospital, Copenhagen, Denmark
| | - Flemming J Olsen
- Cardiovascular Non-Invasive Imaging Research Laboratory, Department of Cardiology, Herlev & Gentofte Hospital, Copenhagen, Denmark
| | - Thomas Fritz-Hansen
- Cardiovascular Non-Invasive Imaging Research Laboratory, Department of Cardiology, Herlev & Gentofte Hospital, Copenhagen, Denmark
| | - Elke Platz
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | | | - Tor Biering-Sørensen
- Cardiovascular Non-Invasive Imaging Research Laboratory, Department of Cardiology, Herlev & Gentofte Hospital, Copenhagen, Denmark.,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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4
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Ford I, Robertson M, Greenlaw N, Bauters C, Lemesle G, Sorbets E, Ferrari R, Tardif JC, Tendera M, Fox K, Steg PG. Simple risk models to predict cardiovascular death in patients with stable coronary artery disease. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 7:287-294. [PMID: 31922541 PMCID: PMC8092988 DOI: 10.1093/ehjqcco/qcz070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 12/20/2019] [Accepted: 01/06/2020] [Indexed: 11/12/2022]
Abstract
AIMS Risk estimation is important to motivate patients to adhere to treatment and to identify those in whom additional treatments may be warranted and expensive treatments might be most cost effective. Our aim was to develop a simple risk model based on readily available risk factors for patients with stable coronary artery disease (CAD). METHODS AND RESULTS Models were developed in the CLARIFY registry of patients with stable CAD, first incorporating only simple clinical variables and then with the inclusion of assessments of left ventricular function, estimated glomerular filtration rate, and haemoglobin levels. The outcome of cardiovascular death over ∼5 years was analysed using a Cox proportional hazards model. Calibration of the models was assessed in an external study, the CORONOR registry of patients with stable coronary disease. We provide formulae for calculation of the risk score and simple integer points-based versions of the scores with associated look-up risk tables. Only the models based on simple clinical variables provided both good c-statistics (0.74 in CLARIFY and 0.80 or over in CORONOR), with no lack of calibration in the external dataset. CONCLUSION Our preferred model based on 10 readily available variables [age, diabetes, smoking, heart failure (HF) symptom status and histories of atrial fibrillation or flutter, myocardial infarction, peripheral arterial disease, stroke, percutaneous coronary intervention, and hospitalization for HF] had good discriminatory power and fitted well in an external dataset. STUDY REGISTRATION The CLARIFY registry is registered in the ISRCTN registry of clinical trials (ISRCTN43070564).
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Affiliation(s)
- Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Level 11, Boyd Orr Building, Glasgow G12 8QQ, UK
| | - Michele Robertson
- Robertson Centre for Biostatistics, University of Glasgow, Level 11, Boyd Orr Building, Glasgow G12 8QQ, UK
| | - Nicola Greenlaw
- Robertson Centre for Biostatistics, University of Glasgow, Level 11, Boyd Orr Building, Glasgow G12 8QQ, UK
| | - Christophe Bauters
- Cardiology Department, Institut Coeur Poumon, CHU, Université de Lille, Bd du Professeur Jules Leclercq, 59000 Lille, France
| | - Gilles Lemesle
- Cardiology Department, Institut Coeur Poumon, CHU, Université de Lille, Bd du Professeur Jules Leclercq, 59000 Lille, France
| | - Emmanuel Sorbets
- National Heart and Lung Institute, Imperial College, Dovehouse Street London SW3 6LY, UK
- Royal Brompton Hospital, Sydney St, London SW3 6NP, UK
- FACT (French Alliance for Cardiovascular Trials), Université de Paris, and AP-HP, Hopital Bichat, INSERM U1148, 46 rue Henri Huchard 75018 Paris, France
- Université de Paris 13, Sorbonne Paris Cité, AP-HP, Hôpital Avicenne, Bobigny, France
- Université de Paris, AP-HP, Hôtel-Dieu, Centre de Diagnostic et de thérapeutique, 1 rue de la Cité, 75004 Paris, France
| | - Roberto Ferrari
- Centro Cardiologico Universitario di Ferrara, University of Ferrara, Maria Cecilia Hospital, GVM Care & Research, Via Corriera, 1 48010 Cotignola, Ravenna, Italy
| | - Jean-Claude Tardif
- Montreal Heart Institute, 5000 Belanger Street, Montreal, H1T1C8, Université de Montréal, Canada
| | - Michal Tendera
- Department of Cardiology and Structural Heart Disease, Medical School in Katowice, Medical University of Silesia, Ziolowa Str. 45/47, 40-635 Katowice, Poland
| | - Kim Fox
- National Heart and Lung Institute, Imperial College, Dovehouse Street London SW3 6LY, UK
- Royal Brompton Hospital, Sydney St, London SW3 6NP, UK
| | - Philippe Gabriel Steg
- National Heart and Lung Institute, Imperial College, Dovehouse Street London SW3 6LY, UK
- Royal Brompton Hospital, Sydney St, London SW3 6NP, UK
- FACT (French Alliance for Cardiovascular Trials), Université de Paris, and AP-HP, Hopital Bichat, INSERM U1148, 46 rue Henri Huchard 75018 Paris, France
- Université de Paris 13, Sorbonne Paris Cité, AP-HP, Hôpital Avicenne, Bobigny, France
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5
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Reeh J, Therming CB, Heitmann M, Højberg S, Sørum C, Bech J, Husum D, Dominguez H, Sehestedt T, Hermann T, Hansen KW, Simonsen L, Galatius S, Prescott E. Prediction of obstructive coronary artery disease and prognosis in patients with suspected stable angina. Eur Heart J 2020; 40:1426-1435. [PMID: 30561616 DOI: 10.1093/eurheartj/ehy806] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 05/02/2018] [Accepted: 11/12/2018] [Indexed: 11/13/2022] Open
Abstract
AIMS We hypothesized that the modified Diamond-Forrester (D-F) prediction model overestimates probability of coronary artery disease (CAD). The aim of this study was to update the prediction model based on pre-test information and assess the model's performance in predicting prognosis in an unselected, contemporary population suspected of angina. METHODS AND RESULTS We included 3903 consecutive patients free of CAD and heart failure and suspected of angina, who were referred to a single centre for assessment in 2012-15. Obstructive CAD was defined from invasive angiography as lesion requiring revascularization, >70% stenosis or fractional flow reserve <0.8. Patients were followed (mean follow-up 33 months) for myocardial infarction, unstable angina, heart failure, stroke, and death. The updated D-F prediction model overestimated probability considerably: mean pre-test probability was 31.4%, while only 274 (7%) were diagnosed with obstructive CAD. A basic prediction model with age, gender, and symptoms demonstrated good discrimination with C-statistics of 0.86 (95% CI 0.84-0.88), while a clinical prediction model adding diabetes, family history, and dyslipidaemia slightly improved the C-statistic to 0.88 (0.86-0.90) (P for difference between models <0.0001). Quartiles of probability of CAD from the clinical prediction model provided good diagnostic and prognostic stratification: in the lowest quartiles there were no cases of obstructive CAD and cumulative risk of the composite endpoint was less than 3% at 2 years. CONCLUSION The pre-test probability model recommended in current ESC guidelines substantially overestimates likelihood of CAD when applied to a contemporary, unselected, all-comer population. We provide an updated prediction model that identifies subgroups with low likelihood of obstructive CAD and good prognosis in which non-invasive testing may safely be deferred.
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Affiliation(s)
- Jacob Reeh
- Department of Cardiology, Bispebjerg Frederiksberg University Hospital, Bispebjerg Bakke 23, DK-2400 Copenhagen, Denmark
| | - Christina Bachmann Therming
- Department of Cardiology, Bispebjerg Frederiksberg University Hospital, Bispebjerg Bakke 23, DK-2400 Copenhagen, Denmark
| | - Merete Heitmann
- Department of Cardiology, Bispebjerg Frederiksberg University Hospital, Bispebjerg Bakke 23, DK-2400 Copenhagen, Denmark
| | - Søren Højberg
- Department of Cardiology, Bispebjerg Frederiksberg University Hospital, Bispebjerg Bakke 23, DK-2400 Copenhagen, Denmark
| | - Charlotte Sørum
- Department of Cardiology, Bispebjerg Frederiksberg University Hospital, Bispebjerg Bakke 23, DK-2400 Copenhagen, Denmark
| | - Jan Bech
- Department of Cardiology, Bispebjerg Frederiksberg University Hospital, Bispebjerg Bakke 23, DK-2400 Copenhagen, Denmark
| | - Dorte Husum
- Department of Cardiology, Bispebjerg Frederiksberg University Hospital, Bispebjerg Bakke 23, DK-2400 Copenhagen, Denmark
| | - Helena Dominguez
- Department of Cardiology, Bispebjerg Frederiksberg University Hospital, Bispebjerg Bakke 23, DK-2400 Copenhagen, Denmark
| | - Thomas Sehestedt
- Department of Cardiology, Bispebjerg Frederiksberg University Hospital, Bispebjerg Bakke 23, DK-2400 Copenhagen, Denmark
| | - Thomas Hermann
- Department of Cardiology, Bispebjerg Frederiksberg University Hospital, Bispebjerg Bakke 23, DK-2400 Copenhagen, Denmark
| | - Kim Wadt Hansen
- Department of Cardiology, Bispebjerg Frederiksberg University Hospital, Bispebjerg Bakke 23, DK-2400 Copenhagen, Denmark
| | - Lene Simonsen
- Department of Clinical Physiology and Nuclear Medicine, Bispebjerg Frederiksberg University Hospital, Bispebjerg Bakke 23, DK-2400 Copenhagen, Denmark
| | - Søren Galatius
- Department of Cardiology, Bispebjerg Frederiksberg University Hospital, Bispebjerg Bakke 23, DK-2400 Copenhagen, Denmark
| | - Eva Prescott
- Department of Cardiology, Bispebjerg Frederiksberg University Hospital, Bispebjerg Bakke 23, DK-2400 Copenhagen, Denmark
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6
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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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7
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Williams MC, Shambrook J, Nicol ED. Assessment of patients with stable chest pain. Heart 2017; 104:691-699. [PMID: 29084808 DOI: 10.1136/heartjnl-2017-311212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 08/11/2017] [Accepted: 09/17/2017] [Indexed: 11/03/2022] Open
Affiliation(s)
- Michelle C Williams
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - James Shambrook
- Department of Cardiothoracic Radiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Edward D Nicol
- Departments of Cardiology and Radiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,Faculty of Health Sciences, National Heart and Lung Institute, Imperial College London, London, UK
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8
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Timmis A, Roobottom CA. National Institute for Health and Care Excellence updates the stable chest pain guideline with radical changes to the diagnostic paradigm. Heart 2017; 103:982-986. [PMID: 28446550 DOI: 10.1136/heartjnl-2015-308341] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 02/19/2017] [Accepted: 03/07/2017] [Indexed: 01/09/2023] Open
Abstract
In the 2016 update of the stable chest pain guideline, the National Institute for Health and Care Excellence (NICE) has made radical changes to the diagnostic paradigm that it-like other international guidelines-had previously placed at the centre of its recommendations. No longer are quantitative assessments of the disease probability considered necessary to determine the need for diagnostic testing and the choice of test. Instead, the recommendation is for no diagnostic testing if chest pain is judged to be 'non-anginal' and CT coronary angiography (CTCA) in patients with 'typical' or 'atypical' chest pain with additional perfusion imaging only if there is uncertainty about the functional significance of coronary lesions. The new emphasis on anatomical-as opposed to functional-testing is driven in large part by cost-effectiveness analysis and despite inevitable resource implications NICE calculates that annual savings for the population of England will be significant. In making CTCA the default diagnostic testing strategy in its updated chest pain guideline, NICE has responded emphatically to calls from trialists for CTCA to have a greater role in the diagnostic pathway of patients with suspected angina.
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Affiliation(s)
- Adam Timmis
- NIHR Cardiovascular Biomedical Research Unit, Bart's Heart Centre, London, UK
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Abstract
Coronary artery disease (CAD) continues to be a leading cause of morbidity and mortality worldwide. Although invasive coronary angiography has previously been the gold standard in establishing the diagnosis of CAD, there is a growing shift to more appropriately use the cardiac catheterization laboratory to perform interventional procedures once a diagnosis of CAD has been established by noninvasive imaging modalities rather than using it primarily as a diagnostic facility to confirm or refute CAD. With ongoing technological advancements, noninvasive imaging plays a pre-eminent role in not only diagnosing CAD but also informing the choice of appropriate therapies, establishing prognosis, all while containing costs and providing value-based care. Multiple imaging modalities are available to evaluate patients suspected of having coronary ischemia, such as stress electrocardiography, stress echocardiography, single-photon emission computed tomography myocardial perfusion imaging, positron emission tomography, coronary computed tomography (CT) angiography, and magnetic resonance imaging. These imaging modalities can variably provide functional and anatomical delineation of coronary stenoses and help guide appropriate therapy. This review will discuss their advantages and limitations and their usage in the diagnostic pathway for patients with CAD. We also discuss newer technologies such as CT fractional flow reserve, CT angiography with perfusion, whole-heart coronary magnetic resonance angiography with perfusion, which can provide both anatomical as well as functional information in the same test, thus obviating the need for multiple diagnostic tests to obtain a comprehensive assessment of both, plaque burden and downstream ischemia. Recognizing that clinicians have a multitude of tests to choose from, we provide an underpinning of the principles of ischemia detection by these various modalities, focusing on anatomy vs physiology, the database justifying their use, their prognostic capabilities and lastly, their appropriate and judicious use in this era of patient-centered, cost-effective imaging.
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