比较纳入冠状动脉钙评分的风险评估策略与预测概率估计，以推迟稳定型胸痛患者的心血管检查。
Comparison of risk assessment strategies incorporating coronary artery calcium score with estimation of pretest probability to defer cardiovascular testing in patients with stable chest pain.
机构信息
Department of Kidney Disease and Blood Purification, The Second Hospital of Tianjin Medical University, Tianjin, China.
Department of Cardiology, Tianjin Chest Hospital, Tianjin, China.
出版信息
BMC Cardiovasc Disord. 2023 Jan 28;23(1):53. doi: 10.1186/s12872-023-03076-3.
BACKGROUND
The risk assessment of patients with stable chest pain (SCP) to defer further cardiovascular testing is crucial, but the most appropriate risk assessment strategy remains unknown. We aimed to compare current strategies to identify low risk SCP patients.
METHODS
5289 symptomatic patients who had undergone coronary artery calcium score (CACS) and coronary computed tomographic angiography scan were identified and followed. Pretest probability (PTP) of obstructive coronary artery disease (CAD) for every patient was estimated according to European Society of Cardiology (ESC)-PTP model and CACS-weighted clinical likelihood (CACS-CL) model, respectively. Based on the 2019 ESC guideline-determined risk assessment strategy (ESC strategy) and CACS-CL model-based risk assessment strategy (CACS-CL strategy), all patients were divided into low and high risk group, respectively. Area under receiver operating characteristic curve (AUC), integrated discrimination improvement (IDI) and net reclassification improvement (NRI) was used.
RESULTS
CACS-CL model provided more robust estimation of PTP than ESC-PTP model did, with a larger AUC (0.838 versus 0.735, p < 0.0001), positive IDI (9%, p < 0.0001) and less discrepancy between observed and predicted probabilities. As a result, compared to ESC strategy which only applied CACS-CL model to patients with borderline ESC-PTP, CACS-CL strategy incorporating CACS with estimation of PTP to entire SCP patients indicated a positive NRI (19%, p < 0.0001) and a stronger association to major adverse cardiovascular events, with hazard ratios: 3.97 (95% confidence intervals: 2.75-5.72) versus 5.11 (95% confidence intervals: 3.40-7.69).
CONCLUSION
The additional use of CACS for all SCP patients in CACS-CL strategy improved the risk assessment of SCP patients to identify individuals at low risk.
背景
稳定型胸痛（SCP）患者的风险评估对于推迟进一步心血管检查至关重要，但最合适的风险评估策略仍不清楚。我们旨在比较目前用于识别低危 SCP 患者的策略。
方法
确定并随访了 5289 例有症状且已行冠状动脉钙评分（CACS）和冠状动脉计算机断层扫描血管造影检查的患者。根据欧洲心脏病学会（ESC）-PTP 模型和 CACS 加权临床似然度（CACS-CL）模型，分别估算每位患者阻塞性冠状动脉疾病（CAD）的术前概率（PTP）。根据 2019 年 ESC 指南确定的风险评估策略（ESC 策略）和基于 CACS-CL 模型的风险评估策略（CACS-CL 策略），将所有患者分为低危和高危组。采用受试者工作特征曲线下面积（AUC）、综合判别改善（IDI）和净重新分类改善（NRI）进行评估。
结果
与 ESC-PTP 模型相比，CACS-CL 模型对 PTP 的估计更稳健，AUC 更大（0.838 比 0.735，p<0.0001），阳性 IDI（9%，p<0.0001）和观测概率与预测概率之间的差异更小。因此，与仅将 CACS-CL 模型应用于 ESC-PTP 边界患者的 ESC 策略相比，将 CACS 与 PTP 估计结合应用于所有 SCP 患者的 CACS-CL 策略可提供正 NRI（19%，p<0.0001），并与主要不良心血管事件有更强的关联，危险比：3.97（95%置信区间：2.75-5.72）比 5.11（95%置信区间：3.40-7.69）。
结论
在 CACS-CL 策略中，为所有 SCP 患者额外使用 CACS 可改善 SCP 患者的风险评估，以识别低危个体。
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