Related Experiment Video
Updated: Mar 21, 2026
Signal Acquisition, Score Interpretation, and Economics of a Non-Invasive Point-of-Care Test for Coronary Artery Disease
Published on: August 9, 2024
Utility of the Diamond-Forrester Classification in Stratifying Acute Chest Pain in an Academic Chest Pain Center
Robert F Hamburger1, John A Spertus, David E Winchester
1From the *University of Florida College of Medicine, Gainesville, FL; †Saint Luke's Mid America Heart Institute, Kansas City, MO; ‡University of Missouri-Kansas City School of Medicine, Kansas City, MO; §Malcom Randall VA Medical Center, Gainesville, FL.
Insights
The Diamond-Forrester (DF) model, used for risk stratifying chest pain patients, did not predict obstructive coronary artery disease (CAD) in a contemporary low-risk population. Typical angina classification by DF was not useful for identifying patients with higher symptom burden.
Area of Science:
- Cardiology
- Medical Diagnostics
- Clinical Risk Stratification
Background:
- The Diamond-Forrester (DF) model is frequently utilized for risk stratification in acute chest pain patients due to its predictive capability for obstructive coronary artery disease (CAD).
- Clinical utility of the DF model requires further evaluation within chest pain evaluation centers.
Purpose of the Study:
- To assess the clinical utility of the Diamond-Forrester (DF) model in risk stratification of acute chest pain patients.
- To determine if typical angina classification by the DF model predicts coronary artery disease (CAD) or identifies higher symptom burden in a low-risk population.
Main Methods:
- Prospective registry of consecutive chest pain patients without known CAD or active ischemia.
- Patients classified by cardiovascular risk factors, age, and DF classification.
- Comparison of emergency department course, Duke Activity Status Index (DASI), Seattle Angina Questionnaire (SAQ) scores, hospitalization rates, and testing results between typical and non-typical angina groups.
- Multivariate logistic regression to identify predictors of CAD via computed tomography coronary angiography (CTCA) or positive exercise treadmill testing (ETT).
Main Results:
- Among 209 patients, 46 had typical chest pain and 163 had atypical/noncardiac chest pain.
- No statistically significant differences in risk factors, CTCA, ETT, or cardiac catheterization results between groups.
- SAQ and DASI scores were lower in the typical chest pain group, indicating greater impairment, but differences were not statistically significant.
- DF classification, SAQ, and DASI scores were not predictive of CAD by CTCA in regression analysis.
Conclusions:
- In a contemporary low-risk acute chest pain population, typical angina as defined by the DF classification was not predictive of obstructive coronary artery disease (CAD).
- The DF classification was not useful for identifying patients with a higher symptom burden in this cohort.
- Further research may be needed to refine risk stratification tools for acute chest pain evaluation.
Background:
Because the Diamond-Forrester (DF) model is predictive of obstructive coronary artery disease (CAD), it is often used to risk stratify acute chest pain patients. We sought to further evaluate the clinical utility of the DF model within a chest pain evaluation center.
Methods:
Consecutive patients with chest pain and no known CAD or evidence of active ischemia were asked to participate in a prospective registry. Patients were classified based on cardiovascular risk factors, age, and DF classification. We compared data from the emergency department course, Duke Activity Status Index (DASI) and Seattle Angina Questionnaire (SAQ), hospitalization rates, and results of testing between patients with typical angina and all others. Multivariate logistic regression was also used to assess for predictors of CAD by computed tomography coronary angiography (CTCA) or positive exercise treadmill testing (ETT).
Results:
Among 209 patients, 163 had atypical/noncardiac and 46 had typical chest pain. The SAQ and DASI scores were lower in the typical chest pain group (indicating more severe impairment), which were not statistically significantly different. There were no significant differences in risk factors or the results of CTCA, ETT, or cardiac catheterization. In the regression analysis, SAQ score, DASI score, and DF classification were not predictive of CAD by CTCA. Worsening angina frequency scores on the SAQ were marginally associated with positive ETT (OR, 1.04; P=0.04).
Conclusion:
In a contemporary low-risk acute chest pain population, typical angina, as defined by the DF classification, was not predictive of CAD or useful for identifying patients with higher symptom burden.
Related Concept Videos
01:30Acute Coronary Syndrome III: Diagnostic Studies
01:27Angina II: Classification
01:29Angina III: Clinical Manifestations and Assessment
01:30Heart Failure IV: Classification and Diagnostic Evaluation
01:30Acute Coronary Syndrome I: Introduction
01:25Imaging Studies for Cardiovascular System VI: Calcium -Scoring CT