Bittencourt Marcio Sommer, Hulten Edward, Polonsky Tamar S, Hoffman Udo, Nasir Khurram, Abbara Suhny, Di Carli Marcelo, Blankstein Ron
From the Center for Clinical and Epidemiological Research, University Hospital and São Paulo State Cancer Institute, University of São Paulo School of Medicine, Sao Paulo, Brazil (M.S.B.); Cardiovascular Imaging Program, Departments of Medicine and Radiology; Brigham and Women's Hospital; Harvard Medical School, Boston, MA (M.S.B., E.H., M.D.C., R.B.); Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil (M.S.B.); Cardiology Service, Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD (E.H.); Department of Medicine, University of Chicago, Chicago, IL (T.S.P.); Cardiac MR PET CT Program, Department of Radiology, Division of Cardiac Imaging, Massachusetts General Hospital; Harvard Medical School, Boston (U.H., S.A.); Baptist Health South Florida, Miami, FL (K.N.); and Department of Radiology, University of Texas Southwestern, Dallas (S.A.).
Circulation. 2016 Jul 19;134(3):201-11. doi: 10.1161/CIRCULATIONAHA.116.023396. Epub 2016 Jul 13.
The most appropriate score for evaluating the pretest probability of obstructive coronary artery disease (CAD) is unknown. We sought to compare the Diamond-Forrester (DF) score with the 2 CAD consortium scores recently recommended by the European Society of Cardiology.
We included 2274 consecutive patients (age, 56±13 years; 57% male) without prior CAD referred for coronary computed tomographic angiography. Computed tomographic angiography findings were used to determine the presence or absence of obstructive CAD (≥50% stenosis). We compared the DF score with the 2 CAD consortium scores with respect to their ability to predict obstructive CAD and the potential implications of these scores on the downstream use of testing for CAD, as recommended by current guidelines.
The DF score did not satisfactorily fit the data and resulted in a significant overestimation of the prevalence of obstructive CAD (P<0.001); the CAD consortium basic score had no significant lack of fitness; and the CAD consortium clinical provided adequate goodness of fit (P=0.39). The DF score had a lower discrimination for obstructive CAD, with an area under the receiver-operating characteristics curve of 0.713 versus 0.752 and 0.791 for the CAD consortium models (P<0.001 for both). Consequently, the use of the DF score was associated with fewer individuals being categorized as requiring no additional testing (8.3%) compared with the CAD consortium models (24.6% and 30.0%; P<0.001). The proportion of individuals with a high pretest probability was 18% with the DF and only 1.1% with the CAD consortium scores (P<0.001) CONCLUSIONS: Among contemporary patients referred for noninvasive testing, the DF risk score overestimates the risk of obstructive CAD. On the other hand, the CAD consortium scores offered improved goodness of fit and discrimination; thus, their use could decrease the need for noninvasive or invasive testing while increasing the yield of such tests.
用于评估阻塞性冠状动脉疾病（CAD）的预测试概率的最合适评分尚不清楚。我们试图将戴蒙德 - 福雷斯特（DF）评分与欧洲心脏病学会最近推荐的两种CAD联盟评分进行比较。
我们纳入了2274例连续的无既往CAD史且因冠状动脉计算机断层血管造影而就诊的患者（年龄56±13岁；57%为男性）。计算机断层血管造影结果用于确定是否存在阻塞性CAD（狭窄≥50%）。我们比较了DF评分与两种CAD联盟评分在预测阻塞性CAD方面的能力，以及这些评分对CAD检测下游应用的潜在影响，这是当前指南所推荐的。
DF评分不能令人满意地拟合数据，导致对阻塞性CAD患病率的显著高估（P<0.001）；CAD联盟基础评分没有明显的拟合不足；CAD联盟临床评分具有足够的拟合优度（P=0.39）。DF评分对阻塞性CAD的鉴别能力较低，其受试者工作特征曲线下面积为0.713，而CAD联盟模型分别为0.752和0.791（两者P<0.001）。因此，与CAD联盟模型（24.6%和30.0%）相比，使用DF评分被归类为无需进一步检测的个体较少（8.3%；P<0.001）。预测试概率高的个体比例在DF评分为18%，而在CAD联盟评分为仅1.1%（P<0.001）。结论：在当代接受无创检测的患者中，DF风险评分高估了阻塞性CAD的风险。另一方面，CAD联盟评分具有更好的拟合优度和鉴别能力；因此，使用它们可以减少对无创或有创检测的需求，同时提高此类检测的阳性率。
