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Diagnostic and Prognostic Role of the Modified Diamond-Forrester Model in Combination With Coronary Calcium Score in
Philip Lavenburg1, Gregg Cantor1, Olufunmilayo Agunloye1
1From the Department of Internal Medicine, Stony Brook University Medical Center, Stony Brook, NY.
Insights
The Diamond-Forrester Model (DFM) with coronary calcium scoring (CCS) effectively rules out major adverse cardiovascular events (MACE) in low-risk chest pain patients. However, CCS alone is insufficient for high-risk patients with obstructive coronary artery disease (CAD).
Area of Science:
- Cardiology
- Medical Imaging
- Risk Stratification
Background:
- Evaluating pretest probability (PTP) using the Diamond-Forrester Model (DFM) combined with coronary calcium scoring (CCS).
- Assessing the safety of ruling out obstructive coronary artery disease (CAD) and 30-day major adverse cardiovascular events (MACE).
- Focusing on patients presenting with acute chest pain, negative initial ECG, and normal troponin levels.
Purpose of the Study:
- To determine if DFM and CCS can safely exclude obstructive CAD.
- To assess the ability to rule out 30-day MACE in acute chest pain patients.
- To investigate the role of CCS in different PTP categories.
Main Methods:
- Retrospective evaluation of 1988 adult patients with no known CAD.
- Coronary computed tomographic angiography (CCTA) with CCS performed on all patients.
- Classification of patients into low (<10%), intermediate (10%-90%), and high (>90%) PTP groups using DFM.
Main Results:
- Low PTP by DFM showed a 0.0% 30-day MACE rate.
- Intermediate PTP with CCS ≤10 had a 99.2% negative predictive value for 30-day MACE.
- High PTP patients, even with CCS of zero, had a 7.07% MACE and 10.1% obstructive CAD prevalence.
Conclusions:
- Low PTP (DFM) or intermediate PTP with CCS ≤10 effectively rule out 30-day MACE in acute chest pain patients.
- CCS alone is insufficient to exclude obstructive CAD and MACE in patients with high PTP.
- Combined DFM and CCS improve risk stratification for acute chest pain evaluation.
Background:
The aim of this study was to evaluate whether pretest probability (PTP) assessment using the Diamond-Forrester Model (DFM) combined with coronary calcium scoring (CCS) can safely rule out obstructive coronary artery disease (CAD) and 30-day major adverse cardiovascular events (MACE) in acute chest pain patients.
Methods:
We retrospectively evaluated consecutive patients, age ≥18 years, with no known CAD, negative initial electrocardiogram, and troponin level. All patients had coronary computed tomographic angiography (CCTA) with CCS, and our final cohort consisted of 1988 patients. Obstructive CAD was defined as luminal narrowing of ≥50% in 1 or more vessels by CCTA. Patients were classified according to PTP as low (<10%), intermediate (10%-90%), or high (>90%).
Results:
The DFM classified 293 (14.7%), 1445 (72.7%), and 250 (12.6%) of patients as low, intermediate, and high risk, respectively, with corresponding 30-day MACE rates of 0.0%, 2.35%, and 14.8%. For patients with intermediate PTP and CCS ≤10, the negative predictive value was 99.2% (95% confidence interval: 98.7-99.8) for 30-day MACE while it was 92.62% (95% confidence interval: 87.9-97.3) for patients with high PTP. Among patients with a high PTP and CCS of zero, the prevalence of 30-day MACE and obstructive CAD remained high (7.07% and 10.1%, respectively).
Conclusions:
In acute chest pain patients without evidence of ischemia on initial electrocardiogram and cardiac troponin, low PTP by DFM or the combination of intermediate PTP and CCS ≤10 had excellent negative predictive values to rule out 30-day MACE. CCS is not sufficient to exclude obstructive CAD and 30-day MACE in patients with high PTP.
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