title: A clinical model to identify patients with high-risk coronary artery disease.
abstract: OBJECTIVE
  This study sought to develop a clinical model that identifies patients with and without high-risk coronary artery disease (CAD).
  
  
  BACKGROUND
  Although current clinical models help to estimate a patient's pre-test probability of obstructive CAD, they do not accurately identify those patients with and without high-risk coronary anatomy.
  
  
  METHODS
  Retrospective analysis of a prospectively collected multinational coronary computed tomographic angiography (CTA) cohort was conducted. High-risk anatomy was defined as left main diameter stenosis ≥50%, 3-vessel disease with diameter stenosis ≥70%, or 2-vessel disease involving the proximal left anterior descending artery. Using a cohort of 27,125, patients with a history of CAD, cardiac transplantation, and congenital heart disease were excluded. The model was derived from 24,251 consecutive patients in the derivation cohort and an additional 7,333 nonoverlapping patients in the validation cohort.
  
  
  RESULTS
  The risk score consisted of 9 variables: age, sex, diabetes, hypertension, current smoking, hyperlipidemia, family history of CAD, history of peripheral vascular disease, and chest pain symptoms. Patients were divided into 3 risk categories: low (≤7 points), intermediate (8 to 17 points) and high (≥18 points). The model was statistically robust with area under the curve of 0.76 (95% confidence interval [CI]: 0.75 to 0.78) in the derivation cohort and 0.71 (95% CI: 0.69 to 0.74) in the validation cohort. Patients who scored ≤7 points had a low negative likelihood ratio (<0.1), whereas patients who scored ≥18 points had a high specificity of 99.3% and a positive likelihood ratio (8.48). In the validation group, the prevalence of high-risk CAD was 1% in patients with ≤7 points and 16.7% in those with ≥18 points.
  
  
  CONCLUSIONS
  We propose a scoring system, based on clinical variables, that can be used to identify patients at high and low pre-test probability of having high-risk CAD. Identification of these populations may detect those who may benefit from a trial of medical therapy and those who may benefit most from an invasive strategy.
authors: Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Canada.
authors: Yelin
authors: Y
authors: Yang
authors: Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Canada.
authors: Li
authors: L
authors: Chen
authors: Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Canada.
authors: Yeung
authors: Y
authors: Yam
authors: Department of Medicine, University of Erlangen, Erlangen, Germany.
authors: Stephan
authors: S
authors: Achenbach
authors: Department of Medicine, Wayne State University, Henry Ford Hospital, Detroit, Michigan.
authors: Mouaz
authors: M
authors: Al-Mallah
authors: Department of Imaging, Cedars Sinai Medical Center, Los Angeles, California.
authors: Daniel S
authors: DS
authors: Berman
authors: Department of Medicine, Harbor UCLA Medical Center, Los Angeles, California.
authors: Matthew J
authors: MJ
authors: Budoff
authors: Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy; Department of Radiology, Erasmus Medical Center, Rotterdam, the Netherlands.
authors: Filippo
authors: F
authors: Cademartiri
authors: Tennessee Heart and Vascular Institute, Hendersonville, Tennessee.
authors: Tracy Q
authors: TQ
authors: Callister
authors: Division of Cardiology, Severance Cardiovascular Hospital, Seoul South Korea.
authors: Hyuk-Jae
authors: HJ
authors: Chang
authors: Department of Imaging, Cedars Sinai Medical Center, Los Angeles, California.
authors: Victor Y
authors: VY
authors: Cheng
authors: Department of Cardiology, William Beaumont Hospital, Royal Oak, Michigan.
authors: Kavitha
authors: K
authors: Chinnaiyan
authors: Baptist Cardiac and Vascular Institute, Miami, Florida.
authors: Ricardo
authors: R
authors: Cury
authors: Capitol Cardiology Associates, Albany, New York.
authors: Augustin
authors: A
authors: Delago
authors: Department of Public Health, Weill Cornell Medical College and the New York Presbyterian Hospital, New York, New York.
authors: Allison
authors: A
authors: Dunning
authors: Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria.
authors: Gudrun
authors: G
authors: Feuchtner
authors: Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria.
authors: Martin
authors: M
authors: Hadamitzky
authors: Division of Cardiology, Technische Universität München, Munich, Germany.
authors: Jörg
authors: J
authors: Hausleiter
authors: Cardiovascular Medical Group, Los Angeles, California.
authors: Ronald P
authors: RP
authors: Karlsberg
authors: Cardiac Imaging, University Hospital, Zurich, Switzerland.
authors: Philipp A
authors: PA
authors: Kaufmann
authors: Seoul National University Hospital, Seoul, South Korea.
authors: Yong-Jin
authors: YJ
authors: Kim
authors: Department of Medicine and Radiology, University of British Columbia, Vancouver, Canada.
authors: Jonathon
authors: J
authors: Leipsic
authors: Department of Imaging, Cedars Sinai Medical Center, Los Angeles, California.
authors: Troy
authors: T
authors: LaBounty
authors: Department of Medicine, Weill Cornell Medical College and the New York Presbyterian Hospital, New York, New York; Department of Radiology, Weill Cornell Medical College and the New York Presbyterian Hospital, New York, New York.
authors: Fay
authors: F
authors: Lin
authors: Department of Radiology, Giovanni XXIII Hospital, Monastier di Treviso, Italy; Department of Radiology, Erasmus Medical Center, Rotterdam, the Netherlands.
authors: Erica
authors: E
authors: Maffei
authors: Department of Cardiology, William Beaumont Hospital, Royal Oak, Michigan.
authors: Gilbert L
authors: GL
authors: Raff
authors: Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.
authors: Leslee J
authors: LJ
authors: Shaw
authors: Department of Medicine, Walter Reed Medical Center, Washington, DC.
authors: Todd C
authors: TC
authors: Villines
authors: Department of Imaging, Cedars Sinai Medical Center, Los Angeles, California.
authors: James K
authors: JK
authors: Min
authors: Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Canada. Electronic address: bchow@ottawaheart.ca.
authors: Benjamin J W
authors: BJW
authors: Chow
mesh_terms: D000368:Aged; D017023:Coronary Angiography / Q000379:methods*; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D014057:Tomography, X-Ray Computed / Q000379:methods*
keywords: computed tomographic coronary angiography; high-risk coronary artery disease; risk factors