Yield of contemporary clinical strategies to detect patients with obstructive coronary artery disease
Abstract
Overview
Purpose. Noninvasive ischemia testing (NIST) is recommended for most patients suspected to have stable coronary
artery disease (CAD) before invasive coronary angiography (ICA). We sought to assess the diagnostic predictive
ability of NIST over clinical risk profiling in a contemporary sample of patients undergoing the currently
recommended diagnostic triage strategy.
Methods. From 2006 to 2011, 2,600 consecutive patients without known CAD undergoing elective ICA in a single
tertiary-care center were retrospectively identified and the prevalence of obstructive CAD determined. To understand
the incremental value of frequently used clinical parameters in predicting obstructive CAD, receiver
operating characteristic curves were plotted for six sequential models starting with Framingham risk score and
then progressively adding multiple clinical factors and finally NIST results.
Results. At ICA 1,268 patients (48.8%) had obstructive CAD. The vast majority (85%) were classified in an intermediate
clinical pretest probability of CAD and NIST prior to ICA was used in 86% of the cohort. The most powerful
correlate of obstructive CAD was the presence of severe angina (odds ratio (OR) = 9.1; 95% confidence interval
(CI) 4.3-19.1). Accordingly, the incorporation of NIST in a sequential model had no significant effect on the predictive
ability over that achieved by clinical and symptomatic status model (C-statistic 0.754; 95% CI 0.732-0.776,
p = 0.28).
Conclusions. Less than half the patients with suspect stable obstructive CAD referred to a tertiary-level center for
elective ICA had the diagnosis confirmed. In this clinical setting, the results of NIST may not have the power to
change the discriminative ability over clinical judgment alone.
Keywords
Angiography, Coronary disease, Diagnosis
Article Information
Disclosure
Financial support: No grants or funding have been received for this
study.
Correspondence
Pedro Rio Santa Marta Hospital Rua de Santa Marta 1169-024, Lisbon, Portugal pedrosantosrio@gmail.com
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