Dataset Information

Pretest probability for patients with suspected obstructive coronary artery disease: re-evaluating Diamond-Forrester for the contemporary era and clinical implications: insights from the PROMISE trial.

ABSTRACT: AIMS:To update pretest probabilities (PTP) for obstructive coronary artery disease (CAD???50%) across age, sex, and clinical symptom strata, using coronary computed tomography angiography (CTA) in a large contemporary population of patients with stable chest pain referred to non-invasive testing. METHODS AND RESULTS:We included patients enrolled in the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial and randomized to CTA. Exclusively level III-certified readers, blinded to demographic and clinical data, assessed the prevalence of CAD???50% in a central core lab. After comparing the recent European Society of Cardiology-Diamond and Forrester PTP (ESC-DF) with the actual observed prevalence of CAD???50%, we created a new PTP set by replacing the ESC-DF PTP with the observed prevalence of CAD???50% across strata of age, sex, and type of angina. In 4415 patients (48.3% men; 60.5?±?8.2?years; 78% atypical angina; 11% typical angina; 11% non-anginal chest pain), the observed prevalence of CAD???50% was 13.9%, only one-third of the average ESC-DF PTP (40.6; P?

SUBMITTER: Foldyna B

PROVIDER: S-EPMC6477645 | biostudies-literature | 2019 May

REPOSITORIES: biostudies-literature

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Pretest probability for patients with suspected obstructive coronary artery disease: re-evaluating Diamond-Forrester for the contemporary era and clinical implications: insights from the PROMISE trial.

Foldyna Borek B Udelson James E JE Karády Júlia J Banerji Dahlia D Lu Michael T MT Mayrhofer Thomas T Bittner Daniel O DO Meyersohn Nandini M NM Emami Hamed H Genders Tessa S S TSS Fordyce Christopher B CB Ferencik Maros M Douglas Pamela S PS Hoffmann Udo U

European heart journal. Cardiovascular Imaging 20190501 5

<h4>Aims</h4>To update pretest probabilities (PTP) for obstructive coronary artery disease (CAD ≥ 50%) across age, sex, and clinical symptom strata, using coronary computed tomography angiography (CTA) in a large contemporary population of patients with stable chest pain referred to non-invasive testing.<h4>Methods and results</h4>We included patients enrolled in the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial and randomized to CTA. Exclusively level III-ce ...[more]

PMID: 30520944

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Project description:ImportanceIn patients with suspected pulmonary embolism (PE), overuse of diagnostic imaging is an important point of concern.ObjectiveTo derive and validate a 4-level pretest probability rule (4-Level Pulmonary Embolism Clinical Probability Score [4PEPS]) that makes it possible to rule out PE solely on clinical criteria and optimized D-dimer measurement to safely decrease imaging testing for suspected PE.Design, setting, and participantsThis study included consecutive outpatients suspected of having PE from US and European emergency departments. Individual data from 3 merged management studies (n = 11 114; overall prevalence of PE, 11%) were used for the derivation cohort and internal validation cohort. The external validation cohorts were taken from 2 independent studies, the first with a high PE prevalence (n = 1548; prevalence, 21.5%) and the second with a moderate PE prevalence (n = 1669; prevalence, 11.7%). A prior definition of pretest probability target values to achieve a posttest probability less than 2% was used on the basis of the negative likelihood ratios of D-dimer. Data were collected from January 2003 to April 2016, and data were analyzed from June 2018 to August 2019.Main outcomes and measuresThe rate of PE diagnosed during the initial workup or during follow-up and the rate of imaging testing.ResultsOf the 5588 patients in the derivation cohort, 3441 (61.8%) were female, and the mean (SD) age was 52 (18.5) years. The 4PEPS comprises 13 clinical variables scored from -2 to 5. It results in the following strategy: (1) very low probability of PE if 4PEPS is less than 0: PE ruled out without testing; (2) low probability of PE if 4PEPS is 0 to 5: PE ruled out if D-dimer level is less than 1.0 μg/mL; (3) moderate probability of PE if 4PEPS is 6 to 12: PE ruled out if D-dimer level is less than the age-adjusted cutoff value; (4) high probability of PE if 4PEPS is greater than 12: PE ruled out by imaging without preceding D-dimer test. In the first and the second external validation cohorts, the area under the receiver operator characteristic curves were 0.79 (95% CI, 0.76 to 0.82) and 0.78 (95% CI, 0.74 to 0.81), respectively. The false-negative testing rates if the 4PEPS strategy had been applied were 0.71% (95% CI, 0.37 to 1.23) and 0.89% (95% CI, 0.53 to 1.49), respectively. The absolute reductions in imaging testing were -22% (95% CI, -26 to -19) and -19% (95% CI, -22 to -16) in the first and second external validation cohorts, respectively. The 4PEPS strategy compared favorably with all recent strategies in terms of imaging testing.Conclusions and relevanceThe 4PEPS strategy may lead to a substantial and safe reduction in imaging testing for patients with suspected PE. It should now be tested in a formal outcome study.

Dataset Information

Pretest probability for patients with suspected obstructive coronary artery disease: re-evaluating Diamond-Forrester for the contemporary era and clinical implications: insights from the PROMISE trial.

Publications

Pretest probability for patients with suspected obstructive coronary artery disease: re-evaluating Diamond-Forrester for the contemporary era and clinical implications: insights from the PROMISE trial.

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