更新后的 Diamond-Forrester、CAD 联合会和 CONFIRM 基于病史的风险评分在预测稳定型胸痛患者中阻塞性冠状动脉疾病的比较：SCOT-HEART 冠状动脉 CTA 队列研究。
A Comparison of the Updated Diamond-Forrester, CAD Consortium, and CONFIRM History-Based Risk Scores for Predicting Obstructive Coronary Artery Disease in Patients With Stable Chest Pain: The SCOT-HEART Coronary CTA Cohort.
机构信息
Department of Radiology, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York, New York; National Heart Centre, Singapore.
Department of Radiology, New York-Presbyterian Hospital and the Weill Cornell Medical College, New York, New York.
出版信息
JACC Cardiovasc Imaging. 2019 Jul;12(7 Pt 2):1392-1400. doi: 10.1016/j.jcmg.2018.02.020. Epub 2018 Apr 18.
OBJECTIVES
This study sought to compare the performance of history-based risk scores in predicting obstructive coronary artery disease (CAD) among patients with stable chest pain from the SCOT-HEART study.
BACKGROUND
Risk scores for estimating pre-test probability of CAD are derived from referral-based populations with a high prevalence of disease. The generalizability of these scores to lower prevalence populations in the initial patient encounter for chest pain is uncertain.
METHODS
We compared 3 scores among patients with suspected CAD in the coronary computed tomographic angiography (CTA) randomized arm of the SCOT-HEART study for the outcome of obstructive CAD by coronary CTA: the updated Diamond-Forrester score (UDF), CAD Consortium clinical score (CAD2), and CONFIRM risk score (CRS). We tested calibration with goodness-of-fit, discrimination with area under the receiver-operating curve (AUC), and reclassification with net reclassification improvement (NRI) to identify low-risk patients.
RESULTS
In 1,738 patients (age 58 ± 10 years and 44.0% women), overall calibration was best for UDF, with underestimation by CRS and CAD2. Discrimination by AUC was highest for CAD2 at 0.79 (95% confidence interval [CI]: 0.77 to 0.81) than for UDF (0.77 [95% CI: 0.74 to 0.79]) or CRS (0.75 [95% CI: 0.73 to 0.77]) (p < 0.001 for both comparisons). Reclassification of low-risk patients at the 10% probability threshold was best for CAD2 (NRI 0.31, 95% CI: 0.27 to 0.35) followed by CRS (NRI 0.21, 95% CI: 0.17 to 0.25) compared with UDF (p < 0.001 for all comparisons), with a consistent trend at the 15% threshold.
CONCLUSIONS
In this multicenter clinic-based cohort of patients with suspected CAD and uniform CAD evaluation by coronary CTA, CAD2 provided the best discrimination and classification, despite overestimation of obstructive CAD as evaluated by coronary CTA. CRS exhibited intermediate performance followed by UDF for discrimination and reclassification.
目的
本研究旨在比较基于病史的风险评分在预测稳定型胸痛患者阻塞性冠状动脉疾病（CAD）方面的表现，该研究来自 SCOT-HEART 研究。
背景
用于估计 CAD 术前概率的风险评分来自于基于转诊人群的高患病率，其在初始胸痛患者就诊中对低患病率人群的通用性尚不确定。
方法
我们比较了 SCOT-HEART 研究冠状动脉计算机断层扫描血管造影（CTA）随机分组中疑似 CAD 患者的 3 种评分，以评估冠状动脉 CTA 显示的阻塞性 CAD 结局：更新的 Diamond-Forrester 评分（UDF）、CAD 联合会临床评分（CAD2）和 CONFIRM 风险评分（CRS）。我们通过拟合优度检验进行校准，通过接受者操作特征曲线下面积（AUC）进行区分，并通过净重新分类改善（NRI）来识别低危患者。
结果
在 1738 例患者（年龄 58±10 岁，44.0%为女性）中，总体校准效果最好的是 UDF，而 CRS 和 CAD2 则存在低估。AUC 区分度最高的是 CAD2，为 0.79（95%置信区间：0.77 至 0.81），优于 UDF（0.77 [95%置信区间：0.74 至 0.79]）或 CRS（0.75 [95%置信区间：0.73 至 0.77]）（两者比较均 p<0.001）。在 10%概率阈值下，低危患者的重新分类效果最佳的是 CAD2（NRI 0.31，95%置信区间：0.27 至 0.35），其次是 CRS（NRI 0.21，95%置信区间：0.17 至 0.25），优于 UDF（所有比较均 p<0.001），在 15%阈值下也呈现出一致的趋势。
结论
在这项基于多中心临床的疑似 CAD 患者队列研究中，通过冠状动脉 CTA 进行了统一的 CAD 评估，CAD2 提供了最佳的区分度和分类，尽管冠状动脉 CTA 评估存在对阻塞性 CAD 的高估。CRS 的表现居中，其次是 UDF 的区分度和重新分类。
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