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      What's the risk? Assessment of patients with stable chest pain

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          Abstract

          In 2010, the National Institute for Heath and Clinical Excellence published guidelines for the management of stable chest pain of recent onset. Implementation has occurred to various degrees throughout the NHS; however, its effectiveness has yet to be proved. A retrospective study was undertaken to assess the impact and relevance of this guideline, comparing the estimated risk of coronary artery disease (CAD) with angiographic outcomes. Findings were compared with the recently published equivalent European guideline. A total of 457 patients who attended a Rapid Access Chest Pain Clinic were retrospectively reviewed. CAD risk was assessed according to NICE guidelines and patients were separated into typical, atypical and non-anginal chest pain groups. Risk stratification using typicality of symptoms in conjunction with NICE risk scoring and exercise tolerance testing was used to determine the best clinical course for each patient. The results include non-anginal chest pain – 92% discharged without needing further testing; atypical angina – 15% discharged, 40% referred for stress echocardiography, 35% referred for angiogram and significant CAD revealed in 8%; typical angina – 4% discharged, 19% referred for stress echocardiography, 71% referred for angiogram and 40% demonstrated CAD. Both guidelines appear to overestimate the risk of CAD leading to an excessive number of coronary angiograms being undertaken to investigate patients with typical or atypical sounding angina, with a low pick up rate of CAD. Given the high negative predictive value of stress echocardiography and the confidence this brings, there is much scope for expanding its use and potentially reduce the numbers going for invasive angiography.

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          Most cited references 7

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          A clinical prediction rule for the diagnosis of coronary artery disease: validation, updating, and extension.

          The aim was to validate, update, and extend the Diamond-Forrester model for estimating the probability of obstructive coronary artery disease (CAD) in a contemporary cohort. Prospectively collected data from 14 hospitals on patients with chest pain without a history of CAD and referred for conventional coronary angiography (CCA) were used. Primary outcome was obstructive CAD, defined as ≥ 50% stenosis in one or more vessels on CCA. The validity of the Diamond-Forrester model was assessed using calibration plots, calibration-in-the-large, and recalibration in logistic regression. The model was subsequently updated and extended by revising the predictive value of age, sex, and type of chest pain. Diagnostic performance was assessed by calculating the area under the receiver operating characteristic curve (c-statistic) and reclassification was determined. We included 2260 patients, of whom 1319 had obstructive CAD on CCA. Validation demonstrated an overestimation of the CAD probability, especially in women. The updated and extended models demonstrated a c-statistic of 0.79 (95% CI 0.77-0.81) and 0.82 (95% CI 0.80-0.84), respectively. Sixteen per cent of men and 64% of women were correctly reclassified. The predicted probability of obstructive CAD ranged from 10% for 50-year-old females with non-specific chest pain to 91% for 80-year-old males with typical chest pain. Predictions varied across hospitals due to differences in disease prevalence. Our results suggest that the Diamond-Forrester model overestimates the probability of CAD especially in women. We updated the predictive effects of age, sex, type of chest pain, and hospital setting which improved model performance and we extended it to include patients of 70 years and older.
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            Value of the history and physical in identifying patients at increased risk for coronary artery disease.

            To determine whether information from the physician's initial evaluation of patients with suspected coronary artery disease predicts coronary anatomy at catheterization and 3-year survival. Prospective validation of regression model estimates in an outpatient cohort. University medical center. A total of 1030 consecutive outpatients referred for noninvasive testing for suspected coronary artery disease; 168 of these patients subsequently underwent catheterization within 90 days. Information from the initial history, physical examination, electrocardiogram, and chest radiograph was used to predict coronary anatomy (the likelihood of any significant coronary disease, severe disease [left main or three-vessel], and significant left main disease) among 168 catheterized patients and to estimate 3-year survival among all patients. These estimates were compared with those based on treadmill testing. Cardiovascular testing charges were calculated for all patients. Predicted coronary anatomy and survival closely corresponded to actual findings. Compared with the treadmill exercise test, initial evaluation was slightly better able to distinguish patients with or without any coronary disease and was similar in the ability to identify patients at increased risk for dying or with anatomically severe disease. Based on arbitrary definitions, 37% to 66% of patients were at low risk and responsible for 31% to 56% of the charges for cardiovascular testing. The physician's initial evaluation, despite the subjective nature of much of the information gathered, can be used to identify patients likely to benefit from further testing. The development of strategies for cost-conscious quality care must begin with the history, physical examination, and simple laboratory testing.
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              Prediction model to estimate presence of coronary artery disease: retrospective pooled analysis of existing cohorts

              Objectives To develop prediction models that better estimate the pretest probability of coronary artery disease in low prevalence populations. Design Retrospective pooled analysis of individual patient data. Setting 18 hospitals in Europe and the United States. Participants Patients with stable chest pain without evidence for previous coronary artery disease, if they were referred for computed tomography (CT) based coronary angiography or catheter based coronary angiography (indicated as low and high prevalence settings, respectively). Main outcome measures Obstructive coronary artery disease (≥50% diameter stenosis in at least one vessel found on catheter based coronary angiography). Multiple imputation accounted for missing predictors and outcomes, exploiting strong correlation between the two angiography procedures. Predictive models included a basic model (age, sex, symptoms, and setting), clinical model (basic model factors and diabetes, hypertension, dyslipidaemia, and smoking), and extended model (clinical model factors and use of the CT based coronary calcium score). We assessed discrimination (c statistic), calibration, and continuous net reclassification improvement by cross validation for the four largest low prevalence datasets separately and the smaller remaining low prevalence datasets combined. Results We included 5677 patients (3283 men, 2394 women), of whom 1634 had obstructive coronary artery disease found on catheter based coronary angiography. All potential predictors were significantly associated with the presence of disease in univariable and multivariable analyses. The clinical model improved the prediction, compared with the basic model (cross validated c statistic improvement from 0.77 to 0.79, net reclassification improvement 35%); the coronary calcium score in the extended model was a major predictor (0.79 to 0.88, 102%). Calibration for low prevalence datasets was satisfactory. Conclusions Updated prediction models including age, sex, symptoms, and cardiovascular risk factors allow for accurate estimation of the pretest probability of coronary artery disease in low prevalence populations. Addition of coronary calcium scores to the prediction models improves the estimates.
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                Author and article information

                Journal
                Echo Res Pract
                Echo Res Pract
                echo
                Echo Res Pract
                Echo Research and Practice
                Bioscientifica Ltd (Bristol )
                2055-0464
                9 March 2015
                1 June 2015
                : 2
                : 2
                : 41-48
                Affiliations
                Cardio-Respiratory Department, Macclesfield District General Hospital , Victoria Road, Macclesfield, SK10 3BL, UK
                Author notes
                Correspondence should be addressed to A Cubukcu Email: acubukcu@ 123456nhs.net
                Article
                ERP140110
                10.1530/ERP-14-0110
                4676449
                © 2015 The authors
                Categories
                Research

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