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Brix GS, Rasmussen LD, Rohde PD, Schmidt SE, Nyegaard M, Douglas PS, Newby DE, Williams MC, Foldyna B, Knuuti J, Bøttcher M, Winther S. Calcium Scoring Improves Clinical Management in Patients With Low Clinical Likelihood of Coronary Artery Disease. JACC Cardiovasc Imaging 2024:S1936-878X(23)00527-2. [PMID: 38180413 DOI: 10.1016/j.jcmg.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 10/30/2023] [Accepted: 11/20/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Coronary artery calcium scoring (CACS) improves management of chest pain patients. However, it is unknown whether the benefit of CACS is dependent on the clinical likelihood (CL). OBJECTIVES This study aims to investigate for which patients CACS has the greatest benefit when added to a CL model. METHODS Based on data from a clinical database, the CL of obstructive coronary artery disease (CAD) was calculated for 39,837 patients referred for cardiac imaging due to symptoms suggestive of obstructive CAD. Patients were categorized according to the risk factor-weighted (RF-CL) model (very low, ≤5%; low, >5 to ≤15%; moderate >15 to ≤50%; high, >50%). CL was then recalculated incorporating the CACS result (CACS-CL). Reclassification rates and the number needed to test with CACS to reclassify patients were calculated and validated in 3 independent cohorts (n = 9,635). RESULTS In total, 15,358 (39%) patients were down- or upclassified after including CACS. Reclassification rates were 8%, 75%, 53%, and 30% in the very low, low, moderate, and high RF-CL categories, respectively. Reclassification to very low CACS-CL occurred in 48% of reclassified patients. The number needed to test to reclassify 1 patient from low RF-CL to very low CACS-CL was 2.1 with consistency across age, sex, and cohorts. CACS-CL correlated better to obstructive CAD prevalence than RF-CL. CONCLUSIONS Added to an RF-CL model for obstructive CAD, CACS identifies more patients unlikely to benefit from further testing. The number needed to test with CACS to reclassify patients depends on the pretest RF-CL and is lowest in patients with low (>5% to ≤15%) likelihood of CAD.
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Affiliation(s)
- Gitte S Brix
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Laust D Rasmussen
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Palle D Rohde
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Samuel E Schmidt
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Mette Nyegaard
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland, UK
| | - Michelle C Williams
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland, UK
| | - Borek Foldyna
- Department of Radiology, Cardiovascular Imaging Research Center, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts, USA
| | - Juhani Knuuti
- Turku PET Centre, Turku University Hospital, University of Turku, Kiinamyllynkatu, Turku, Finland
| | - Morten Bøttcher
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Simon Winther
- Department of Cardiology, Gødstrup Hospital, Herning, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
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Rasmussen LD, Albertsen LEB, Nissen L, Ejlersen JA, Isaksen C, Murphy T, Søndergaard HM, Kirk J, Brix L, Gormsen LC, Petersen SE, Bøttcher M, Winther S. Diagnostic performance of clinical likelihood models of obstructive coronary artery disease to predict myocardial perfusion defects. Eur Heart J Cardiovasc Imaging 2023; 25:39-47. [PMID: 37282714 DOI: 10.1093/ehjci/jead135] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/18/2023] [Accepted: 06/02/2023] [Indexed: 06/08/2023] Open
Abstract
AIMS Clinical likelihood (CL) models are designed based on a reference of coronary stenosis in patients with suspected obstructive coronary artery disease. However, a reference standard for myocardial perfusion defects (MPDs) could be more appropriate. We aimed to investigate the ability of the 2019 European Society of Cardiology pre-test probability (ESC-PTP), the risk-factor-weighted (RF-CL) model, and coronary artery calcium score-weighted (CACS-CL) model to diagnose MPDs. METHODS AND RESULTS Symptomatic stable de novo chest pain patients (n = 3374) underwent coronary computed tomography angiography and subsequent myocardial perfusion imaging by single-photon emission computed tomography, positron emission tomography, or cardiac magnetic resonance. For all modalities, MPD was defined as coronary computed tomography angiography with suspected stenosis and stress-perfusion abnormality in ≥2 segments. The ESC-PTP was calculated based on age, sex, and symptom typicality, and the RF-CL and CACS-CL additionally included a number of risk factors and CACS. In total, 219/3374 (6.5%) patients had an MPD. Both the RF-CL and the CACS-CL classified substantially more patients to low CL (<5%) of obstructive coronary artery disease compared with the ESC-PTP (32.5 and 54.1 vs. 12.0%, P < 0.001) with preserved low prevalences of MPD (<2% for all models). Compared with the ESC-PTP [area under the receiver-operating characteristic curve (AUC) 0.74 (0.71-0.78)], the discrimination of having an MPD was higher for the CACS-CL model [AUC 0.88 (0.86-0.91), P < 0.001], while it was similar for the RF-CL model [AUC 0.73 (0.70-0.76), P = 0.32]. CONCLUSION Compared with basic CL models, the RF-CL and CACS-CL models improve down classification of patients to a very low-risk group with a low prevalence of MPD.
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Affiliation(s)
- Laust Dupont Rasmussen
- Department of Cardiology, Gødstrup Hospital, Hospitalsparken 15, Herning DK-7400, Denmark
| | | | - Louise Nissen
- Department of Cardiology, Gødstrup Hospital, Hospitalsparken 15, Herning DK-7400, Denmark
| | | | - Christin Isaksen
- Department of Radiology, Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Theodore Murphy
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, UK
| | | | - Jane Kirk
- Department of Cardiology, Regional Hospital Central Jutland, Silkeborg, Denmark
| | - Lau Brix
- Department of Radiology, Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Comparative Medicine Lab, Aarhus University, Aarhus, Denmark
| | - Lars Christian Gormsen
- Department of Nuclear Medicine and PET Centre, Aarhus University Hospital, Aarhus, Denmark
| | - Steffen E Petersen
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, UK
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University London, Charterhouse Square, London, UK
| | - Morten Bøttcher
- Department of Cardiology, Gødstrup Hospital, Hospitalsparken 15, Herning DK-7400, Denmark
| | - Simon Winther
- Department of Cardiology, Gødstrup Hospital, Hospitalsparken 15, Herning DK-7400, Denmark
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