Author + information
- Received January 26, 2018
- Revision received February 22, 2018
- Accepted February 23, 2018
- Published online July 1, 2019.
- Lohendran Baskaran, MDa,b,
- Ibrahim Danad, MDa,
- Heidi Gransar, MSa,
- Bríain Ó Hartaigh, PhDa,
- Joshua Schulman-Marcus, MDa,
- Fay Y. Lin, MDa,
- Jessica M. Peña, MD, MPHa,
- Amanda Hunter, MDc,
- David E. Newby, MDc,
- Philip D. Adamson, MDc,∗ and
- James K. Min, MDa,∗∗ ()
- aDepartment of Radiology, New York–Presbyterian Hospital and the Weill Cornell Medical College, New York, New York
- bNational Heart Centre, Singapore
- cUniversity of Edinburgh/BHF Centre for Cardiovascular Science, Edinburgh, United Kingdom
- ↵∗Address for correspondence:
Dr. James K. Min, Dalio Institute of Cardiovascular Imaging, Weill Cornell Medical College, 413 East 69th Street, New York, New York 10021.
Objectives This study sought to compare the performance of history-based risk scores in predicting obstructive coronary artery disease (CAD) among patients with stable chest pain from the SCOT-HEART study.
Background Risk scores for estimating pre-test probability of CAD are derived from referral-based populations with a high prevalence of disease. The generalizability of these scores to lower prevalence populations in the initial patient encounter for chest pain is uncertain.
Methods We compared 3 scores among patients with suspected CAD in the coronary computed tomographic angiography (CTA) randomized arm of the SCOT-HEART study for the outcome of obstructive CAD by coronary CTA: the updated Diamond-Forrester score (UDF), CAD Consortium clinical score (CAD2), and CONFIRM risk score (CRS). We tested calibration with goodness-of-fit, discrimination with area under the receiver-operating curve (AUC), and reclassification with net reclassification improvement (NRI) to identify low-risk patients.
Results In 1,738 patients (age 58 ± 10 years and 44.0% women), overall calibration was best for UDF, with underestimation by CRS and CAD2. Discrimination by AUC was highest for CAD2 at 0.79 (95% confidence interval [CI]: 0.77 to 0.81) than for UDF (0.77 [95% CI: 0.74 to 0.79]) or CRS (0.75 [95% CI: 0.73 to 0.77]) (p < 0.001 for both comparisons). Reclassification of low-risk patients at the 10% probability threshold was best for CAD2 (NRI 0.31, 95% CI: 0.27 to 0.35) followed by CRS (NRI 0.21, 95% CI: 0.17 to 0.25) compared with UDF (p < 0.001 for all comparisons), with a consistent trend at the 15% threshold.
Conclusions In this multicenter clinic-based cohort of patients with suspected CAD and uniform CAD evaluation by coronary CTA, CAD2 provided the best discrimination and classification, despite overestimation of obstructive CAD as evaluated by coronary CTA. CRS exhibited intermediate performance followed by UDF for discrimination and reclassification.
- coronary artery disease
- coronary computed tomography angiography
- pre-test probability
- risk score
↵∗ Drs. Adamson and Min contributed equally to this work and are joint senior authors.
This work is supported in part by the Dalio Institute of Cardiovascular Imaging and the Michael Wolk Foundation. Dr. Min has served as a consultant to HeartFlow and Abbott Vascular; on the medical advisory boards of GE Healthcare and Arineta; as a consultant for HeartFlow, NeoGraft Technologies, MyoKardia, and CardioDx; and holds ownership in MDDX and AutoPlaq. Dr. Newby has received honoraria and consultancy from Toshiba Medical Systems; and is also supported by the British Heart Foundation (CH/09/002) and a Wellcome Trust Senior Investigator Award (WT103782AIA). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Pamela Douglas, MD, served as the Guest Editor for this paper.
- Received January 26, 2018.
- Revision received February 22, 2018.
- Accepted February 23, 2018.
This article requires a subscription or purchase to view the full text. If you are a subscriber or member, click Login or the Subscribe link (top menu above) to access this article.