A1 Refereed original research article in a scientific journal
Clinical Likelihood Prediction of Hemodynamically Obstructive Coronary Artery Disease in Patients With Stable Chest Pain
Authors: Rasmussen, Laust Dupont; Karim, Salma Raghad; Westra, Jelmer; Nissen, Louise; Dahl, Jonathan Nørtoft; Brix, Gitte Stokvad; Knuuti, Juhani; Schmidt, Samuel Emil; Holm, Niels Ramsing; Christiansen, Evald Høj; Eftekhari, Ashkan; Bøttcher, Morten; Winther, Simon
Publisher: American College of Cardiology Foundation
Publication year: 2024
Journal: JACC: Cardiovascular Imaging
Journal name in source: JACC: Cardiovascular Imaging
Volume: 17
Issue: 10
First page : 1199
Last page: 1210
ISSN: 1936-878X
eISSN: 1876-7591
DOI: https://doi.org/10.1016/j.jcmg.2024.04.015
Web address : https://doi.org/10.1016/j.jcmg.2024.04.015
Background: Selection for invasive angiography is recommended to be based on pretest probabilities (PTPs), and physiological measures of hemodynamical impairment by, for example, fractional flow reserve (FFR) should guide revascularization. The risk factor-weighted clinical likelihood (RF-CL) and coronary artery calcium score-weighted clinical likelihood (CACS-CL) models show superior discrimination of patients with suspected obstructive coronary artery disease (CAD), but validation against hemodynamic impairment is warranted.
Objectives: The aim of this study was to validate the RF-CL and CACS-CL models against hemodynamically obstructive CAD.
Methods: Stable de novo chest pain patients (N = 4,371) underwent coronary computed tomography angiography and subsequently invasive coronary angiography with FFR measurements. Hemodynamically obstructive CAD was defined as invasive FFR ≤0.80 or high-grade stenosis by visual assessment (>90% diameter stenosis). For comparison, a guideline-endorsed basic PTP model was calculated based on age, sex, and symptom typicality. The RF-CL model additionally included the number of risk factors, and the CACS-CL model incorporated the coronary artery calcium score into the RF-CL.
Results: In total, 447 of 4,371 (10.9%) patients had hemodynamically obstructive CAD. Both the RF-CL and CACS-CL models classified more patients with a very low clinical likelihood (≤5%) of obstructive CAD compared to the basic PTP model (33.0% and 53.7% vs 12.0%; P < 0.001) with a preserved low prevalence of hemodynamically obstructive CAD (<5% for all models). Against hemodynamically obstructive CAD, calibration and discrimination of the RF-CL and CACS-CL models were superior to the basic PTP model.
Conclusions: The RF-CL and CACS-CL models are well calibrated and superior to a currently recommended basic PTP model to predict hemodynamically obstructive CAD. (Danish Study of Non-Invasive Diagnostic Testing in Coronary Artery Disease [Dan-NICAD]; NCT02264717; Danish Study of Non-Invasive Diagnostic Testing in Coronary Artery Disease 2 [Dan-NICAD 2]; NCT03481712, Danish Study of Non-Invasive Diagnostic Testing in Coronary Artery Disease 3 [Dan-NICAD 3]; NCT04707859).
Funding information in the publication:
Dr Rasmussen has received support in terms of a research grant (PD5Y-2023001-DCA) from the Danish Cardiovascular Academy, which is funded by the Novo Nordisk Foundation, grant number NNF20SA0067242 and The Danish Heart Foundation. Dr Knuuti has received consulting fees from GE Healthcare and Synektik; and has received speaker fees from Lundbeck, Bayer, Boehringer-Ingelheim, Pfizer, and Siemens Healthineers. Dr Schmidt has received a research grant from Acarix AB. Dr Holm has received institutional research grants from Abbott, Boston Scientific, and Medis Medical Imaging; and has received speaker fees from Abbott and Terumo. Dr Christiansen has received consulting fees from Abbott, Phillips, and Boston Scientific. Dr Bøttcher has served on the Advisory Boards for NOVO Nordisk, AstraZeneca, Pfizer, Boehringer Ingelheim, Bayer, Sanofi, Novartis, AMGEN, CLS-Behring, and Acarix. Dr Winther has received support from the Novo Nordisk Foundation Clinical Emerging Investigator grant (NNF21OC0066981). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
