Yield of contemporary clinical strategies to detect patients with obstructive coronary artery disease.
OBJECTIVE
Noninvasive ischemia testing (NIST) is recommended for most patients suspected to have stable coronary artery disease (CAD) before invasive coronary angiography (ICA). We sought to assess the diagnostic predictive ability of NIST over clinical risk profiling in a contemporary sample of patients undergoing the currently recommended diagnostic triage strategy.


METHODS
From 2006 to 2011, 2,600 consecutive patients without known CAD undergoing elective ICA in a single tertiary-care center were retrospectively identified and the prevalence of obstructive CAD determined. To understand the incremental value of frequently used clinical parameters in predicting obstructive CAD, receiver operating characteristic curves were plotted for six sequential models starting with Framingham risk score and then progressively adding multiple clinical factors and finally NIST results.


RESULTS
At ICA 1,268 patients (48.8%) had obstructive CAD. The vast majority (85%) were classified in an intermediate clinical pretest probability of CAD and NIST prior to ICA was used in 86% of the cohort. The most powerful correlate of obstructive CAD was the presence of severe angina (odds ratio (OR) = 9.1; 95% confidence interval (CI) 4.3-19.1). Accordingly, the incorporation of NIST in a sequential model had no significant effect on the predictive ability over that achieved by clinical and symptomatic status model (C-statistic 0.754; 95% CI 0.732-0.776, p = 0.28).


CONCLUSIONS
Less than half the patients with suspect stable obstructive CAD referred to a tertiary-level center for elective ICA had the diagnosis confirmed. In this clinical setting, the results of NIST may not have the power to change the discriminative ability over clinical judgment alone.
Cardiology Department, Santa Marta Hospital, Centro Hospitalar de Lisboa Central, Lisbon - Portugal.
Pedro
P
Rio
Cardiology Department, Santa Marta Hospital, Centro Hospitalar de Lisboa Central, Lisbon - Portugal.
Ruben
R
Ramos
Cardiology Department, Santa Marta Hospital, Centro Hospitalar de Lisboa Central, Lisbon - Portugal.
Tiago
T
Pereira-da-Silva
Cardiology Department, Santa Marta Hospital, Centro Hospitalar de Lisboa Central, Lisbon - Portugal.
Carlos
C
Barbosa
Cardiology Department, Santa Marta Hospital, Centro Hospitalar de Lisboa Central, Lisbon - Portugal.
Duarte
D
Cacela
Cardiology Department, Santa Marta Hospital, Centro Hospitalar de Lisboa Central, Lisbon - Portugal.
António
A
Fiarresga
Cardiology Department, Santa Marta Hospital, Centro Hospitalar de Lisboa Central, Lisbon - Portugal.
Lídia
L
de Sousa
Cardiology Department, Santa Marta Hospital, Centro Hospitalar de Lisboa Central, Lisbon - Portugal.
Ana
A
Abreu
Cardiology Department, Santa Marta Hospital, Centro Hospitalar de Lisboa Central, Lisbon - Portugal.
Lino
L
Patrício
Cardiology Department, Santa Marta Hospital, Centro Hospitalar de Lisboa Central, Lisbon - Portugal.
Luís
L
Bernardes
Cardiology Department, Santa Marta Hospital, Centro Hospitalar de Lisboa Central, Lisbon - Portugal.
Rui Cruz
RC
Ferreira
Angiography; Coronary disease; Diagnosis
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