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      Validation of European Society of Cardiology pre-test probabilities for obstructive coronary artery disease in suspected stable angina

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          To assess contemporary pre-test probability estimates for obstructive coronary artery disease in patients with stable chest pain.

          Methods and results 

          In this substudy of a multicentre randomized controlled trial, we compared 2019 European Society of Cardiology (ESC)-endorsed pre-test probabilities with observed prevalence of obstructive coronary artery disease on computed tomography coronary angiography (CTCA). We assessed associations between pre-test probability, 5-year coronary heart disease death or non-fatal myocardial infarction and study intervention (standard care vs. CTCA). The study population consisted of 3755 patients (30–75 years, 46% women) with a median pre-test probability of 11% of whom 1622 (43%) had a pre-test probability of >15%. In those who underwent CTCA ( n = 1613), the prevalence of obstructive disease was 22%. When divided into deciles of pre-test probability, the observed disease prevalence was similar but higher than the corresponding median pre-test probability [median difference 2.3 (1.3–5.6)%]. There were more clinical events in patients with a pre-test probability >15% compared to those at 5–15% and <5% (4.1%, 1.5%, and 1.4%, respectively, P < 0.001). Across the total cohort, fewer clinical events occurred in patients who underwent CTCA, with the greatest difference in those with a pre-test probability >15% (2.8% vs. 5.3%, log rank P = 0.01), although this interaction was not statistically significant on multivariable modelling.


          The updated 2019 ESC guideline pre-test probability recommendations tended to slightly underestimate disease prevalence in our cohort. Pre-test probability is a powerful predictor of future coronary events and helps select those who may derive the greatest absolute benefit from CTCA.

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          Most cited references 26

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          2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes

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            2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology.

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              Evolving concepts of angiogram: fractional flow reserve discordances in 4000 coronary stenoses.

              The present analysis addresses the potential clinical and physiologic significance of discordance in severity of coronary artery disease between the angiogram and fractional flow reserve (FFR) in a large and unselected patient population.

                Author and article information

                Eur Heart J Qual Care Clin Outcomes
                Eur Heart J Qual Care Clin Outcomes
                European Heart Journal. Quality of Care & Clinical Outcomes
                Oxford University Press
                October 2020
                24 January 2020
                24 January 2020
                : 6
                : 4
                : 293-300
                [q1 ] BHF Centre for Cardiovascular Science , University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
                [q2 ] Usher Institute of Population Health Sciences and Informatics , University of Edinburgh, 9 Little France Road, Edinburgh EH16 4UX, UK
                [q3 ] Christchurch Heart Institute , University of Otago, 2 Riccarton Avenue, Christchurch 8011, New Zealand
                Author notes
                Corresponding author. Email:
                © The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

                Page count
                Pages: 8
                Funded by: Chief Scientist Office of the Scottish Government;
                Award ID: CZH/4/588
                Award ID: PCL/17/04
                Funded by: British Heart Foundation, DOI 10.13039/501100000274;
                Award ID: CH/09/002
                Award ID: RE/13/3/30183
                Award ID: RE/18/5/34216
                Award ID: PG/19/40/34422
                Award ID: RG/16/10/32375
                Award ID: FS/11/014
                Award ID: FS/16/14/32023
                Award ID: FS/14/78/31020
                Funded by: National Heart Foundation of New Zealand, DOI 10.13039/501100001516;
                Funded by: Wellcome Trust, DOI 10.13039/100010269;
                Award ID: WT103782AIA
                Funded by: National Health Service Research Scotland;
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