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Comparison of the Diamond-Forrester method and Duke Clinical Score to predict obstructive coronary artery disease by
Meagan M Wasfy1, Thomas J Brady, Suhny Abbara
1Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Insights
The Duke Clinical Score (DCS) better predicts obstructive coronary artery disease (CAD) on coronary computed tomographic angiography (CCTA) than the Diamond and Forrester method (DFM). DCS improves risk assessment, leading to more appropriate CCTA use, especially for low-risk patients.
Area of Science:
- Cardiology
- Medical Imaging
- Diagnostic Accuracy
Background:
- Accurate pretest risk stratification is crucial for appropriate use of coronary computed tomographic angiography (CCTA).
- Existing risk scores like the Diamond and Forrester method (DFM) and Duke Clinical Score (DCS) have varying abilities to predict obstructive coronary artery disease (CAD).
- The 2010 Appropriate Use Criteria (AUC) guide CCTA indications based on pretest probability and prior testing.
Purpose of the Study:
- To compare the predictive ability of DFM and DCS for obstructive CAD on CCTA.
- To assess the impact of DFM and DCS on CCTA appropriateness using the 2010 AUC.
- To evaluate the net reclassification improvement (NRI) for obstructive CAD prediction and its effect on AUC categories.
Main Methods:
- 114 consecutive symptomatic patients undergoing CCTA for CAD evaluation were analyzed.
- Pretest probability for obstructive CAD was assessed using both DFM and DCS.
- CCTA results were categorized as obstructive (≥70% stenosis), nonobstructive (<70%), or no CAD.
- Appropriateness of CCTA indications was determined based on AUC, considering pretest probability and prior testing.
Main Results:
- DCS reclassified risk for 53% of patients, shifting them from intermediate to low or high risk.
- DCS demonstrated a significant net reclassification improvement (NRI) of 51% (p=0.01) for predicting obstructive CAD.
- 97% of patients reclassified to low risk by DCS did not have obstructive CAD.
- Using DCS instead of DFM led to a 13% reclassification of CCTA appropriateness, with a significant decrease in appropriate examinations (68% vs. 55%, p<0.001).
Conclusions:
- The Duke Clinical Score (DCS) offers superior prediction of obstructive CAD on CCTA compared to the Diamond and Forrester method (DFM).
- Risk reclassification by DCS improves diagnostic accuracy, particularly for identifying low-risk patients without obstructive CAD.
- The shift towards higher pretest probability with DCS can lead to more uncertain or inappropriate CCTA indications, highlighting the need for refined risk assessment tools.
Abstract:
We sought to evaluate the ability of the Diamond and Forrester method (DFM) and the Duke Clinical Score (DCS) to predict obstructive coronary artery disease (CAD) on coronary computed tomographic angiography (CCTA) and the effect of these different risk scores on the appropriateness level using the 2010 Appropriate Use Criteria. Consecutive symptomatic patients who underwent CCTA for evaluation of CAD (n = 114) were classified as having a low, intermediate, or high pretest probability using the DFM and DCS. Using the Appropriate Use Criteria, the indications for CCTA were classified according to the pretest probability and previous testing. The CCTA results were classified as revealing obstructive (≥70% stenosis), nonobstructive (<70%), or no CAD. When the patients' risk was classified using the DFM, 18% were low, 65% intermediate, and 17% high risk. When using the DCS, 53% of patients had a reclassification of their risk, most of whom changed from intermediate to either low or high risk (50% low, 19% intermediate, 35% high risk). The net reclassification improvement for the prediction of obstructive CAD was 51% (p = 0.01). Of the 37 patients who were reclassified as low risk, 36 (97%) lacked obstructive CAD. Appropriateness for CCTA was reclassified for 13% of patients when using the DCS instead of the DFM, and the number of appropriate examinations was significantly fewer (68% vs 55%, p <0.001). In conclusion, reclassification of risk using the DCS instead of the DFM resulted in improved prediction of obstructive CAD on CCTA, especially in low-risk patients. More patients were categorized as having a high pretest probability of CAD, resulting in reclassification of their examination indications as uncertain or inappropriate. These results identify the need for improved pretest risk scores for noninvasive tests such as CCTA and suggest that the method of risk assessment could have important implications for patient selection and quality assurance programs.
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