Implications of three different testing strategies in the diagnostic approach to patients with stable chest pain and low pretest probability of obstructive coronary artery disease
The clinical implications of a widespread adoption of guideline recommendations for patients with stable chest pain and low pretest probability (PTP) of obstructive coronary artery disease (CAD) remain unclear. We aimed to assess the results of three different testing strategies in this subgroup of...
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| Veröffentlicht in: | Journal of cardiovascular computed tomography 2023-07, Vol.17 (4), p.248-253 |
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| creator | Lopes, Pedro M. Ferreira, António M. Albuquerque, Francisco Freitas, Pedro de Araújo Gonçalves, Pedro Presume, João Abecasis, João Guerreiro, Sara Santos, Ana Coutinho Saraiva, Carla Mendes, Miguel Marques, Hugo |
| description | The clinical implications of a widespread adoption of guideline recommendations for patients with stable chest pain and low pretest probability (PTP) of obstructive coronary artery disease (CAD) remain unclear. We aimed to assess the results of three different testing strategies in this subgroup of patients: A) defer testing; B) perform coronary artery calcium score (CACS), withholding further testing if CACS = 0 and proceeding to coronary computed tomography angiography (CCTA) if CACS>0; C) perform CCTA in all.
Two-center cross-sectional study assessing 1328 symptomatic patients undergoing CACS and CCTA for suspected CAD. PTP was calculated based on age, sex and symptom typicality. Obstructive CAD was defined as any luminal stenosis ≥50% on CCTA.
The prevalence of obstructive CAD was 8.6% (n = 114). In the 786 patients (56.8%) with CACS = 0, 8.5% (n = 67) had some degree of CAD [1.9% (n = 15) obstructive, and 6.6% (n = 52) nonobstructive]. Among those with CACS>0 (n = 542), 18.3% (n = 99) had obstructive CAD. The number of patients needed to scan (NNS) to identify one patient with obstructive CAD was 13 for strategy B vs. A, and 91 for strategy C vs. B.
Using CACS as gatekeeper would decrease CCTA use by more than 50%, at the cost of missing obstructive CAD in one in 100 patients. These findings may help inform decisions on testing, which will ultimately depend on the willingness to accept some diagnostic uncertainty.
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| doi_str_mv | 10.1016/j.jcct.2023.06.001 |
| format | Article |
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Two-center cross-sectional study assessing 1328 symptomatic patients undergoing CACS and CCTA for suspected CAD. PTP was calculated based on age, sex and symptom typicality. Obstructive CAD was defined as any luminal stenosis ≥50% on CCTA.
The prevalence of obstructive CAD was 8.6% (n = 114). In the 786 patients (56.8%) with CACS = 0, 8.5% (n = 67) had some degree of CAD [1.9% (n = 15) obstructive, and 6.6% (n = 52) nonobstructive]. Among those with CACS>0 (n = 542), 18.3% (n = 99) had obstructive CAD. The number of patients needed to scan (NNS) to identify one patient with obstructive CAD was 13 for strategy B vs. A, and 91 for strategy C vs. B.
Using CACS as gatekeeper would decrease CCTA use by more than 50%, at the cost of missing obstructive CAD in one in 100 patients. These findings may help inform decisions on testing, which will ultimately depend on the willingness to accept some diagnostic uncertainty.
[Display omitted]</description><identifier>ISSN: 1934-5925</identifier><identifier>EISSN: 1876-861X</identifier><identifier>DOI: 10.1016/j.jcct.2023.06.001</identifier><identifier>PMID: 37308356</identifier><language>eng</language><publisher>United States: Elsevier Inc</publisher><subject>Coronary artery calcium score ; Coronary artery disease ; Coronary computed tomography angiography ; Gatekeeper ; Low pretest probability</subject><ispartof>Journal of cardiovascular computed tomography, 2023-07, Vol.17 (4), p.248-253</ispartof><rights>2023 Society of Cardiovascular Computed Tomography</rights><rights>Copyright © 2023 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c356t-dd7d96db7a666347558fa72723dabb82223af92d071b7438c00dab5f5d4c50293</citedby><cites>FETCH-LOGICAL-c356t-dd7d96db7a666347558fa72723dabb82223af92d071b7438c00dab5f5d4c50293</cites><orcidid>0000-0003-4301-3090 ; 0000-0002-4741-8178 ; 0000-0001-9968-477X ; 0000-0002-1536-7855 ; 0000-0002-0078-6512 ; 0000-0001-8210-2075</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktohtml>$$Uhttps://www.sciencedirect.com/science/article/pii/S1934592523003714$$EHTML$$P50$$Gelsevier$$H</linktohtml><link.rule.ids>314,776,780,3537,27901,27902,65306</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/37308356$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Lopes, Pedro M.</creatorcontrib><creatorcontrib>Ferreira, António M.</creatorcontrib><creatorcontrib>Albuquerque, Francisco</creatorcontrib><creatorcontrib>Freitas, Pedro</creatorcontrib><creatorcontrib>de Araújo Gonçalves, Pedro</creatorcontrib><creatorcontrib>Presume, João</creatorcontrib><creatorcontrib>Abecasis, João</creatorcontrib><creatorcontrib>Guerreiro, Sara</creatorcontrib><creatorcontrib>Santos, Ana Coutinho</creatorcontrib><creatorcontrib>Saraiva, Carla</creatorcontrib><creatorcontrib>Mendes, Miguel</creatorcontrib><creatorcontrib>Marques, Hugo</creatorcontrib><title>Implications of three different testing strategies in the diagnostic approach to patients with stable chest pain and low pretest probability of obstructive coronary artery disease</title><title>Journal of cardiovascular computed tomography</title><addtitle>J Cardiovasc Comput Tomogr</addtitle><description>The clinical implications of a widespread adoption of guideline recommendations for patients with stable chest pain and low pretest probability (PTP) of obstructive coronary artery disease (CAD) remain unclear. We aimed to assess the results of three different testing strategies in this subgroup of patients: A) defer testing; B) perform coronary artery calcium score (CACS), withholding further testing if CACS = 0 and proceeding to coronary computed tomography angiography (CCTA) if CACS>0; C) perform CCTA in all.
Two-center cross-sectional study assessing 1328 symptomatic patients undergoing CACS and CCTA for suspected CAD. PTP was calculated based on age, sex and symptom typicality. Obstructive CAD was defined as any luminal stenosis ≥50% on CCTA.
The prevalence of obstructive CAD was 8.6% (n = 114). In the 786 patients (56.8%) with CACS = 0, 8.5% (n = 67) had some degree of CAD [1.9% (n = 15) obstructive, and 6.6% (n = 52) nonobstructive]. Among those with CACS>0 (n = 542), 18.3% (n = 99) had obstructive CAD. The number of patients needed to scan (NNS) to identify one patient with obstructive CAD was 13 for strategy B vs. A, and 91 for strategy C vs. B.
Using CACS as gatekeeper would decrease CCTA use by more than 50%, at the cost of missing obstructive CAD in one in 100 patients. These findings may help inform decisions on testing, which will ultimately depend on the willingness to accept some diagnostic uncertainty.
[Display omitted]</description><subject>Coronary artery calcium score</subject><subject>Coronary artery disease</subject><subject>Coronary computed tomography angiography</subject><subject>Gatekeeper</subject><subject>Low pretest probability</subject><issn>1934-5925</issn><issn>1876-861X</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2023</creationdate><recordtype>article</recordtype><recordid>eNp9Uctu1DAUtRCIlsIPsEBesknwI7YTiQ2qeFSqxAYkdpZj38x4lImD7WnV7-IHuWEKS1bX8nncxyHkNWctZ1y_O7QH72srmJAt0y1j_Am55L3RTa_5j6f4HmTXqEGoC_KilANjynDWPycX0kjWS6Uvya-b4zpH72pMS6FponWfAWiI0wQZlkorlBqXHS01uwq7CIXGBVkbx-2WhKinbl1zcn5Pa6IreqGw0PtY9yhz4wzU79EGIZS6JdA53dM1Q_3zmdPoxjjH-rD1TyN2Ovka71CVclpcfqAuV8ASYgFX4CV5Nrm5wKvHekW-f_r47fpLc_v18831h9vG42q1CcGEQYfROK217IxS_eSMMEIGN469EEK6aRCBGT6aTvaeMQTUpELnFRODvCJvz7444s8TzmqPsXiYZ7dAOhUreqEU40O3UcWZ6nMqJcNk1xyPOLrlzG5h2YPdwrJbWJZpi2Gh6M2j_2k8Qvgn-ZsOEt6fCYBb3kXItni8rYcQM6BZSPF__r8BdwirMg</recordid><startdate>20230701</startdate><enddate>20230701</enddate><creator>Lopes, Pedro M.</creator><creator>Ferreira, António M.</creator><creator>Albuquerque, Francisco</creator><creator>Freitas, Pedro</creator><creator>de Araújo Gonçalves, Pedro</creator><creator>Presume, João</creator><creator>Abecasis, João</creator><creator>Guerreiro, Sara</creator><creator>Santos, Ana Coutinho</creator><creator>Saraiva, Carla</creator><creator>Mendes, Miguel</creator><creator>Marques, Hugo</creator><general>Elsevier Inc</general><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope><orcidid>https://orcid.org/0000-0003-4301-3090</orcidid><orcidid>https://orcid.org/0000-0002-4741-8178</orcidid><orcidid>https://orcid.org/0000-0001-9968-477X</orcidid><orcidid>https://orcid.org/0000-0002-1536-7855</orcidid><orcidid>https://orcid.org/0000-0002-0078-6512</orcidid><orcidid>https://orcid.org/0000-0001-8210-2075</orcidid></search><sort><creationdate>20230701</creationdate><title>Implications of three different testing strategies in the diagnostic approach to patients with stable chest pain and low pretest probability of obstructive coronary artery disease</title><author>Lopes, Pedro M. ; Ferreira, António M. ; Albuquerque, Francisco ; Freitas, Pedro ; de Araújo Gonçalves, Pedro ; Presume, João ; Abecasis, João ; Guerreiro, Sara ; Santos, Ana Coutinho ; Saraiva, Carla ; Mendes, Miguel ; Marques, Hugo</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c356t-dd7d96db7a666347558fa72723dabb82223af92d071b7438c00dab5f5d4c50293</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2023</creationdate><topic>Coronary artery calcium score</topic><topic>Coronary artery disease</topic><topic>Coronary computed tomography angiography</topic><topic>Gatekeeper</topic><topic>Low pretest probability</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Lopes, Pedro M.</creatorcontrib><creatorcontrib>Ferreira, António M.</creatorcontrib><creatorcontrib>Albuquerque, Francisco</creatorcontrib><creatorcontrib>Freitas, Pedro</creatorcontrib><creatorcontrib>de Araújo Gonçalves, Pedro</creatorcontrib><creatorcontrib>Presume, João</creatorcontrib><creatorcontrib>Abecasis, João</creatorcontrib><creatorcontrib>Guerreiro, Sara</creatorcontrib><creatorcontrib>Santos, Ana Coutinho</creatorcontrib><creatorcontrib>Saraiva, Carla</creatorcontrib><creatorcontrib>Mendes, Miguel</creatorcontrib><creatorcontrib>Marques, Hugo</creatorcontrib><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><jtitle>Journal of cardiovascular computed tomography</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Lopes, Pedro M.</au><au>Ferreira, António M.</au><au>Albuquerque, Francisco</au><au>Freitas, Pedro</au><au>de Araújo Gonçalves, Pedro</au><au>Presume, João</au><au>Abecasis, João</au><au>Guerreiro, Sara</au><au>Santos, Ana Coutinho</au><au>Saraiva, Carla</au><au>Mendes, Miguel</au><au>Marques, Hugo</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Implications of three different testing strategies in the diagnostic approach to patients with stable chest pain and low pretest probability of obstructive coronary artery disease</atitle><jtitle>Journal of cardiovascular computed tomography</jtitle><addtitle>J Cardiovasc Comput Tomogr</addtitle><date>2023-07-01</date><risdate>2023</risdate><volume>17</volume><issue>4</issue><spage>248</spage><epage>253</epage><pages>248-253</pages><issn>1934-5925</issn><eissn>1876-861X</eissn><abstract>The clinical implications of a widespread adoption of guideline recommendations for patients with stable chest pain and low pretest probability (PTP) of obstructive coronary artery disease (CAD) remain unclear. We aimed to assess the results of three different testing strategies in this subgroup of patients: A) defer testing; B) perform coronary artery calcium score (CACS), withholding further testing if CACS = 0 and proceeding to coronary computed tomography angiography (CCTA) if CACS>0; C) perform CCTA in all.
Two-center cross-sectional study assessing 1328 symptomatic patients undergoing CACS and CCTA for suspected CAD. PTP was calculated based on age, sex and symptom typicality. Obstructive CAD was defined as any luminal stenosis ≥50% on CCTA.
The prevalence of obstructive CAD was 8.6% (n = 114). In the 786 patients (56.8%) with CACS = 0, 8.5% (n = 67) had some degree of CAD [1.9% (n = 15) obstructive, and 6.6% (n = 52) nonobstructive]. Among those with CACS>0 (n = 542), 18.3% (n = 99) had obstructive CAD. The number of patients needed to scan (NNS) to identify one patient with obstructive CAD was 13 for strategy B vs. A, and 91 for strategy C vs. B.
Using CACS as gatekeeper would decrease CCTA use by more than 50%, at the cost of missing obstructive CAD in one in 100 patients. These findings may help inform decisions on testing, which will ultimately depend on the willingness to accept some diagnostic uncertainty.
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| ispartof | Journal of cardiovascular computed tomography, 2023-07, Vol.17 (4), p.248-253 |
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| source | Elsevier ScienceDirect Journals |
| subjects | Coronary artery calcium score Coronary artery disease Coronary computed tomography angiography Gatekeeper Low pretest probability |
| title | Implications of three different testing strategies in the diagnostic approach to patients with stable chest pain and low pretest probability of obstructive coronary artery disease |
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