title: A comparison of Diamond Forrester and coronary calcium scores as gatekeepers for investigations of stable chest pain.
abstract: To determine if calcium scores (CS) could act as a more effective gatekeeper than Diamond Forrester (DF) in the assessment of patients with suspected coronary artery disease (CAD). A sub-study of the Cardiac CT for the Assessment of Chest Pain and Plaque (CAPP) study, a randomised control trial evaluating the cost-effectiveness of cardiac CT in symptomatic patients with stable chest pain. Stable pain was defined as troponin negative pain without symptoms of unstable angina. 250 patients undergoing cardiac CT had both DF scores and CS calculated, with the accuracy of both evaluated against CT coronary angiogram. Criteria given in UK national guidelines were compared. Of the 250 patients, 4 withdrew. 140 (57 %) patients were male. The mean DF was 47.8 and mean CS 172.5. Of the 144 patients with non-anginal pain 19.4 % had significant disease (>50 % stenosis). In general the DF over estimated the presence of CAD whereas the CS reclassified patients to lower risk groups, with 91 in the high risk DF category compared to 26 in the CS. Both receiver operating curve and McNemar Bowker test analysis suggested the DF was less accurate in the prediction of CAD compared to CS [Formula: see text] Projected downstream investigations were also calculated, with the cost per number of significant stenoses identified cheaper with the CS criteria. Patients with suspected stable CAD are more accurately risk stratified by CS compared to the traditional DF. CS was more successful in the prediction of significant stenosis and appears to be more effective at targeting clinical resources to those patients that are in need of them.
authors.affiliation: Cardiology Research Office, Ward 16, Ulster Hospital, South Eastern Health and Social, Care Trust, Upper Newtownards Road, Dundonald, Belfast, BT16 1RH, Northern Ireland, UK, mckavanagh@doctors.net.uk.
authors.forename: Peter
authors.initials: P
authors.lastname: McKavanagh
authors.forename: Lisa
authors.initials: L
authors.lastname: Lusk
authors.forename: Peter A
authors.initials: PA
authors.lastname: Ball
authors.forename: Tom R
authors.initials: TR
authors.lastname: Trinick
authors.forename: Ellie
authors.initials: E
authors.lastname: Duly
authors.forename: Gerard M
authors.initials: GM
authors.lastname: Walls
authors.forename: Clare
authors.initials: C
authors.lastname: Orr
authors.forename: Mark T
authors.initials: MT
authors.lastname: Harbinson
authors.forename: Patrick M
authors.initials: PM
authors.lastname: Donnelly
mesh_terms: D000368:Aged; D002637:Chest Pain / Q000191:economics / Q000209:etiology*; D016009:Chi-Square Distribution; D017023:Coronary Angiography / Q000191:economics / Q000379:methods*; D003324:Coronary Artery Disease / Q000150:complications / Q000000981:diagnostic imaging* / Q000191:economics; D023921:Coronary Stenosis / Q000150:complications / Q000000981:diagnostic imaging* / Q000191:economics; D003362:Cost-Benefit Analysis; D005260:Female; D017721:Hospital Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed / Q000191:economics; D006113:United Kingdom; D061205:Vascular Calcification / Q000150:complications / Q000000981:diagnostic imaging* / Q000191:economics