Luis Eduardo Juarez-Orozco1, Antti Saraste1, Davide Capodanno2, Eva Prescott3, Haitham Ballo1, Jeroen J Bax4, William Wijns5, Juhani Knuuti1. 1. Turku PET Centre, University of Turku and Turku University Hospital, Kiinamyllynkatu 4-8, Turku, Finland. 2. Cardiac-Thoracic-Vascular Department, Azienda Ospedaliero-Universitaria "Policlinico-Vittorio Emanuele", University of Catania, Via Citelli 6, Catania, Italy. 3. Department of Cardiology, Bispebjerg-Frederiksberg University Hospital, Bispebjerg Bakke 23, Copenhagen, Denmark. 4. Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, Leiden, The Netherlands. 5. The Lambe Institute for Translational Medicine and Curam, Saolta University Healthcare Group, National University of Ireland Galway, University College Hospital Galway, Newcastle Rd, Galway, Ireland.
Abstract
AIMS: To provide a pooled estimation of contemporary pre-test probabilities (PTPs) of significant coronary artery disease (CAD) across clinical patient categories, re-evaluate the utility of the application of diagnostic techniques according to such estimates, and propose a comprehensive diagnostic technique selection tool for suspected CAD. METHODS AND RESULTS: Estimates of significant CAD prevalence across sex, age, and type of chest pain categories from three large-scale studies were pooled (n = 15 815). The updated PTPs and diagnostic performance profiles of exercise electrocardiogram, invasive coronary angiography, coronary computed tomography angiography (CCTA), positron emission tomography (PET), stress cardiac magnetic resonance (CMR), and SPECT were integrated to define the PTP ranges in which ruling-out CAD is possible with a post-test probability of <10% and <5%. These ranges were then integrated in a new colour-coded tabular diagnostic technique selection tool. The Bayesian relationship between PTP and the rate of diagnostic false positives was explored to complement the characterization of their utility. Pooled CAD prevalence was 14.9% (range = 1-52), clearly lower than that used in current clinical guidelines. Ruling-out capabilities of non-invasive imaging were good overall. The greatest ruling-out capacity (i.e. post-test probability <5%) was documented by CCTA, PET, and stress CMR. With decreasing PTP, the fraction of false positive findings rapidly increased, although a lower CAD prevalence partially cancels out such effect. CONCLUSION: The contemporary PTP of significant CAD across symptomatic patient categories is substantially lower than currently assumed. With a low prevalence of the disease, non-invasive testing can rarely rule-in the disease and focus should shift to ruling-out obstructive CAD. The large proportion of false positive findings must be taken into account when patients with low PTP are investigated. Published on behalf of the European Society of Cardiology. All rights reserved.
AIMS: To provide a pooled estimation of contemporary pre-test probabilities (PTPs) of significant coronary artery disease (CAD) across clinical patient categories, re-evaluate the utility of the application of diagnostic techniques according to such estimates, and propose a comprehensive diagnostic technique selection tool for suspected CAD. METHODS AND RESULTS: Estimates of significant CAD prevalence across sex, age, and type of chest pain categories from three large-scale studies were pooled (n = 15 815). The updated PTPs and diagnostic performance profiles of exercise electrocardiogram, invasive coronary angiography, coronary computed tomography angiography (CCTA), positron emission tomography (PET), stress cardiac magnetic resonance (CMR), and SPECT were integrated to define the PTP ranges in which ruling-out CAD is possible with a post-test probability of <10% and <5%. These ranges were then integrated in a new colour-coded tabular diagnostic technique selection tool. The Bayesian relationship between PTP and the rate of diagnostic false positives was explored to complement the characterization of their utility. Pooled CAD prevalence was 14.9% (range = 1-52), clearly lower than that used in current clinical guidelines. Ruling-out capabilities of non-invasive imaging were good overall. The greatest ruling-out capacity (i.e. post-test probability <5%) was documented by CCTA, PET, and stress CMR. With decreasing PTP, the fraction of false positive findings rapidly increased, although a lower CAD prevalence partially cancels out such effect. CONCLUSION: The contemporary PTP of significant CAD across symptomatic patient categories is substantially lower than currently assumed. With a low prevalence of the disease, non-invasive testing can rarely rule-in the disease and focus should shift to ruling-out obstructive CAD. The large proportion of false positive findings must be taken into account when patients with low PTP are investigated. Published on behalf of the European Society of Cardiology. All rights reserved.
Authors: Diana M Lopez; Sanjay Divakaran; Ankur Gupta; Navkaranbir S Bajaj; Michael T Osborne; Wunan Zhou; Jon Hainer; Courtney F Bibbo; Hicham Skali; Sharmila Dorbala; Viviany R Taqueti; Ron Blankstein; Marcelo F Di Carli Journal: JACC Cardiovasc Imaging Date: 2021-08-18
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