Abstract
For women presenting with stable chest pain (SCP), the appropriate risk assessment strategy to identify individuals unlikely to benefit from further cardiovascular imaging testing (CIT) is debatable. Thus, the present study intended to compare two risk assessment strategies in these individuals. 2592 women with SCP who underwent coronary computed tomography angiography (CCTA) were divided into low and high risk group according to 2016 National Institute of Health and Care Excellence guideline-determined strategy (NICE strategy) and 2019 European Society of Cardiology guideline-determined strategy (ESC strategy), respectively. The associations of coronary artery disease (CAD), major adverse cardiovascular event (MACE) and other subsequent clinical outcomes with risk groups and net reclassification improvement (NRI) were evaluated to compare different strategies. Both NICE strategy which focused on symptom evaluation and ESC strategy which was based on pretest probability (PTP) determined by ESC-PTP model and coronary artery calcium score-weighted clinical likelihood (CACS-CL) model classified a proportion (34.49% and 63.97%, respectively) of individuals into the low risk group. Compared to NICE strategy, ESC strategy indicated stronger associations between risk groups and obstructive CAD (odds ratio: 27.63 versus 3.57), MACE (hazard ratios: 4.24 versus 1.91), more intensive clinical management as well as a positive NRI (27.71%, p < 0.0001). Compared to NICE strategy, ESC strategy which sequentially incorporated ESC-PTP model with CACS-CL model seemed to be associated with greater effectiveness in identifying individuals who may derive maximum benefit from further CIT in women presenting with SCP.
Highlights
Coronary artery disease (CAD) is a previously underestimated cause of morbidity and mortality in women [1,2]
Data from four large cardiovascular imaging testing (CIT)-based clinical trials demonstrated the discrepancy among high burden of traditional risk factors, atypical symptom and low prevalence of obstructive coronary artery disease (CAD), highlighting the need for optimal strateges to the evaluation and diagnosis of obstructive CAD in women presenting with stable chest pain (SCP) [7,8,9,10]
Only 1 of the 619 individuals suffered from nonfatal myocardial infarction and no individual died in the follow-up. In this coronary computed tomography angiography (CCTA)-based cohort comprised of women with SCP, we demonstrated that based on current two risk assessment strategies, low risk groups were associated with fewer obstructive CAD, major adverse cardiovascular event (MACE) and changes of downstream management than high risk groups did
Summary
Coronary artery disease (CAD) is a previously underestimated cause of morbidity and mortality in women [1,2]. National Institute of Health and Care Excellence (NICE) guideline offered a strategy recommending coronary computed tomography angiography (CCTA) for all individuals with typical and atypical angina or abnormal electrocardiogram (ECG) [11] This symptom-based risk assessment strategy for SCP has been controversial since release [12,13,14] and numerous studies has indicated that atypical symptoms were more likely to be a manifestation of SCP in women [3,4,7,8,9,10]. Results: Both NICE strategy which focused on symptom evaluation and ESC strategy which was based on pretest probability (PTP) determined by ESC-PTP model and coronary artery calcium score-weighted clinical likelihood (CACS-CL) model classified a proportion (34.49% and 63.97%, respectively) of individuals into the low risk group.
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