https://doi.org/10.1007/s00392-025-02625-4
1Universitätsklinikum Essen Klinik für Kardiologie und Angiologie Essen, Deutschland
Background: The European Society of Cardiology (ESC) updated their guidelines on the estimation of the pre-test-probability (PTP) in patients with stable symptoms suggestive of obstructive coronary artery disease in 2024 to improve decision-making on conducting or deferring diagnostic testing in patients with suspected coronary artery disease. The new guideline recommends a risk factor weighted clinical likelihood model to enhance the prediction. We aimed to determine, whether the new model recommended by the 2024 ESC guideline is superior to the model recommended by the 2019 ESC guideline with respect to prediction of obstructive coronary artery disease.
Methods: The present analysis is based on the prospective ECAD II registry of patients admitted to the West German Heart and Vascular Center between 2021 and 2024. For this analysis we included patients with stable symptoms, who underwent coronary angiography and had available information for the assessment of the risk-estimation models recommended by the guidelines mentioned above. Cardiovascular risk factors as well as patients’ symptoms were assessed in standardized manner prior to coronary angiography exams. Obstructive coronary artery disease was defined as the need for revascularization therapy according to the discretion of the interventional cardiologist. The risk was estimated according to the scores from the 2019 and 2024 guidelines and compared to the coronary angiography outcome, calculating measures of diagnostic accuracy.
Results: Both clinical characteristics and coronary angiography exams were available in 3829 patients (mean age 68.9 ± 13.3 years, 65% male). 559 (14.6%) had obstructive coronary artery disease. These patients were older (70.3 vs. 68.6 years, p<0.001), more often male (75.1% vs 63.3%, p<0.001), had a higher BMI (27.9 vs 27.3 kg/m², p<0.001), more often hypertension (76.7% vs. 71.9%, p=0.02) and more often dyslipidaemia (66.9% vs. 57.4%, p<0.001). The 2024 model assigned more cases without coronary artery disease to the very low PTP group (cut off 5% PTP) than the 2019 model (true negatives 493 cases vs. 257 cases) and low PTP group (cut off 15% PTP, true negatives 1480 vs. 1015 cases, Table 1). The correlation between both models was high (r=0.865, p<0.0001). However, the overall area under the receiver operating characteristics curve was only modest and did not significantly increase with the 2024 model (ROC: 0.627 [0.601; 0.654] vs. 0.617[0.589; 0.644], for the 2024 and 2019 model, respectively, p=0.11).
Conclusion: In our prospective large all-comers cohort of patients undergoing coronary angiography, the assessment of pre-test probability using a risk factor weighted clinical likelihood model according to the 2024 ESC guidelines classified more patients into lower probability groups, leading to a down-classification in comparison to the modified Diamond and Forrester model, established in the 2019 ESC guidelines. However, both models only provide modest prediction for the presence of obstructive coronary artery disease without significant improvement from 2019 to 2024 recommendations.
Table 1. Pre-test probability for obstructive coronary artery disease (CAD) according to 2019 vs. 2024 ESC guidelines
|
|
2024 | |||||||||
|
All patients |
Patient with CAD |
Patients without CAD | ||||||||
|
<5% |
5-<15% |
≥15% |
<5% |
5-<15% |
≥15% |
<5% |
5-<15% |
≥15% | ||
|
2019 |
<5% |
255 |
17 |
0 |
14 |
1 |
0 |
241 |
16 |
0 |
|
5-<15% |
260 |
564 |
28 |
25 |
67 |
2 |
235 |
497 |
26 | |
|
≥15% |
17 |
551 |
1200 |
0 |
77 |
256 |
17 |
474 |
944 | |