Division of Cardiology and Centre for Cardiovascular Innovation, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA.
Heart. 2022 May 12;108(11):860-867. doi: 10.1136/heartjnl-2021-320275.
To evaluate informal physician judgement versus pretest probability scores in estimating risk in patients with suspected coronary artery disease (CAD).
We included 4533 patients from the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial. Physicians categorised a priori the pretest probability of obstructive CAD (≥70% or ≥50% left main); Diamond-Forrester (D-F) and European Society of Cardiology (ESC) pretest probability estimates were calculated. Agreement was calculated using the κ statistic; logistic regression evaluated estimates of pretest CAD probability and actual CAD (as determined by CT coronary angiography), and clinical outcomes were modelled using Cox proportional hazard models.
Physician estimates agreed poorly with D-F (κ 0.16; 95% CI 0.14 to 0.18) and ESC (κ 0.04; 95% CI 0.02 to 0.05). Actual obstructive CAD was significantly more prevalent in both the high-likelihood (OR 3.30; 95% CI 2.30 to 4.74) and the intermediate-likelihood (OR 1.43; 95% CI 1.16 to 1.76) physician-estimated groups versus the low-likelihood group; ESC similarly differentiated between the three groups (OR 9.07; 95% CI 2.87 to 28.70; and OR 3.87; 95% CI 1.22 to 12.28). However, using D-F, only the high-probability group differed (OR 2.49; 95% CI 1.74 to 3.54). Only physician estimates were associated with a higher incidence of adjusted death/myocardial infarction/unstable angina hospitalisation in the high-probability versus low-probability group (HR 2.68; 95% CI 1.52 to 4.74); neither pretest probability score provided prognostic information.
Compared with D-F and ESC estimates, physician judgement more accurately identified obstructive CAD and worse patient outcomes. Integrating physician judgement may improve risk prediction for patients with stable chest pain.
NCT01174550.
评估疑似冠心病 (CAD) 患者中，医生的非正规判断与预测概率评分在估计风险方面的作用。
我们纳入了 PROMISE（前瞻性多中心成像研究评估胸痛）试验中的 4533 例患者。医生预先对阻塞性 CAD（≥70%或≥50%左主干）的预测概率进行分类；计算 Diamond-Forrester（D-F）和欧洲心脏病学会（ESC）预测概率估计值。采用κ 统计量评估一致性；逻辑回归评估预测 CAD 概率和实际 CAD（通过 CT 冠状动脉造影确定），使用 Cox 比例风险模型模拟临床结局。
医生的估计与 D-F（κ=0.16；95%CI 0.14 至 0.18）和 ESC（κ=0.04；95%CI 0.02 至 0.05）的一致性较差。在高可能性（OR 3.30；95%CI 2.30 至 4.74）和中可能性（OR 1.43；95%CI 1.16 至 1.76）医生估计组中，实际的阻塞性 CAD 明显更为常见，而在低可能性组中则不常见；ESC 也能区分这三组（OR 9.07；95%CI 2.87 至 28.70；OR 3.87；95%CI 1.22 至 12.28）。然而，仅使用 D-F 时，仅高概率组存在差异（OR 2.49；95%CI 1.74 至 3.54）。仅医生的估计与高可能性组与低可能性组相比，与调整后的死亡/心肌梗死/不稳定型心绞痛住院的发生率较高相关（HR 2.68；95%CI 1.52 至 4.74）；预测概率评分均未提供预后信息。
与 D-F 和 ESC 估计相比，医生的判断更准确地识别出阻塞性 CAD 和更差的患者结局。整合医生的判断可能会改善稳定性胸痛患者的风险预测。
NCT01174550。
