Abstract
Aims To assess contemporary pre-test probability estimates for obstructive coronary artery disease in patients with stable chest pain.Methods and results In this substudy of a multicentre randomized controlled trial, we compared 2019 European Society of Cardiology (ESC)-endorsed pre-test probabilities with observed prevalence of obstructive coronary artery disease on computed tomography coronary angiography (CTCA). We assessed associations between pre-test probability, 5-year coronary heart disease death or non-fatal myocardial infarction and study intervention (standard care vs. CTCA). The study population consisted of 3755 patients (30–75 years, 46% women) with a median pre-test probability of 11% of whom 1622 (43%) had a pre-test probability of >15%. In those who underwent CTCA (n = 1613), the prevalence of obstructive disease was 22%. When divided into deciles of pre-test probability, the observed disease prevalence was similar but higher than the corresponding median pre-test probability [median difference 2.3 (1.3–5.6)%]. There were more clinical events in patients with a pre-test probability >15% compared to those at 5–15% and <5% (4.1%, 1.5%, and 1.4%, respectively, P < 0.001). Across the total cohort, fewer clinical events occurred in patients who underwent CTCA, with the greatest difference in those with a pre-test probability >15% (2.8% vs. 5.3%, log rank P = 0.01), although this interaction was not statistically significant on multivariable modelling.Conclusion The updated 2019 ESC guideline pre-test probability recommendations tended to slightly underestimate disease prevalence in our cohort. Pre-test probability is a powerful predictor of future coronary events and helps select those who may derive the greatest absolute benefit from CTCA.
Highlights
Chest pain is one of the commonest symptoms in patients presenting to the cardiology clinic
We demonstrate that the 2019 European Society of Cardiology (ESC) estimates of pre-test probability for obstructive coronary artery disease in suspected stable angina are broadly similar to the observed prevalence in the SCOT-HEART trial cohort, it tends to underestimate prevalence
In this representative and general population of patients referred with stable chest pain to a cardiology clinic, less than half of patients would need further testing according to the current ESC guidelines
Summary
Chest pain is one of the commonest symptoms in patients presenting to the cardiology clinic. Determining whether obstructive coronary artery disease is the underlying cause requires a combination of clinical evaluation and, where appropriate, non-invasive or invasive investigations. Additional testing should only be applied to an appropriately selected population, taking into account disease prevalence and the diagnostic performance of the test. Inappropriate testing may lead to under or over diagnosis of coronary artery disease, with potential misallocation of downstream invasive angiography and therapies. This is pertinent in the current era, where a broad range of functional and anatomical investigations across a spectrum of cost and availability can be performed. Pre-test probabilities derived from historic cohorts have consistently overestimated contemporary disease prevalence [1,2,3,4], undoubtedly leading to over-testing
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