European Society of Cardiology Recommended CAD Consortium Pre-Test Probability Scores More Accurately Predict Obstructive Coronary Disease and Cardiovascular Events Than the Diamond and Forrester Score: The Partners Registry
Background—The most appropriate score for evaluating the pretest probability of obstructive coronary artery disease (CAD) is unknown. We sought to compare the Diamond Forrester (DF) score with the two CAD consortium scores recently recommended by the European Society of Cardiology.
Methods—We included 2274 consecutive patients (age 56±13 years, 57% males) without prior CAD referred for coronary CT angiography (CTA). CTA findings were used to determine the presence or absence of obstructive CAD (≥50% stenosis). We compared the DF score with the two CAD consortium scores with respect to their ability to predict obstructive CAD as well as the potential implications of these score on downstream utilization of testing for CAD, as recommended by current guidelines.
Results—The DF score did not satisfactorily fit the data, and resulted in a significant overestimation of the prevalence of obstructive CAD (p<0.001), the CAD consortium basic had no significant lack of fitness, while the CAD consortium clinical provided adequate goodness-of-fit (p=0.39). The DF had a lower discrimination for obstructive CAD, with an area under the ROC curve of 0.713 vs. 0.752 and 0.791 for the CAD consortium models (p<0.001 for both). Consequently, the use of the DF score was associated with fewer individuals being categorized as requiring no additional testing (8.3%) when compared to the CAD consortium models (24.6% and 30.0%, p<0.001). The proportion of individuals with a high pretest probability was 18% with the DF and only 1.1% with the CAD consortium scores (p<0.001)
Conclusions—Among contemporary patients referred for non-invasive testing, the DF risk score over estimates the risk of obstructive CAD. On the other hand, the CAD consortium scores offered improved goodness-of-fit and discrimination, and thus their use could decrease the need for non-invasive or invasive testing, while increasing the yield of such tests.
- Received January 11, 2016.
- Revision received June 10, 2016.
- Accepted June 13, 2016.