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Physician judgement in predicting obstructive coronary artery disease and adverse events in chest pain patients
Christopher B Fordyce1, C Larry Hill2, Daniel B Mark2
1Division of Cardiology and Centre for Cardiovascular Innovation, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada cfordyce@mail.ubc.ca.
Insights
Physician judgment better identified coronary artery disease (CAD) risk and patient outcomes than standard scores. Integrating clinical judgment may improve risk prediction for patients with chest pain.
Area of Science:
- Cardiology
- Medical Decision Making
Background:
- Estimating the pretest probability of coronary artery disease (CAD) is crucial for managing patients with suspected CAD.
- Existing pretest probability scores, such as Diamond-Forrester (D-F) and European Society of Cardiology (ESC), have limitations in accurately assessing risk.
Purpose of the Study:
- To compare the accuracy of informal physician judgment against established pretest probability scores (D-F and ESC) in estimating the risk of obstructive CAD.
- To evaluate the association of these risk estimates with actual CAD and clinical outcomes.
Main Methods:
- Analysis of 4533 patients from the PROMISE trial.
- Physicians categorized pretest probability of obstructive CAD; D-F and ESC scores were calculated.
- Agreement assessed using κ statistic; logistic regression and Cox proportional hazard models used for outcome analysis.
Main Results:
- Physician estimates showed poor agreement with D-F (κ=0.16) and ESC (κ=0.04) scores.
- Physician judgment identified significantly higher prevalence of obstructive CAD in high- and intermediate-likelihood groups compared to D-F.
- Physician estimates, but not D-F or ESC, were associated with increased risk of death/myocardial infarction/unstable angina hospitalization.
Conclusions:
- Physician judgment more accurately identified obstructive CAD and predicted worse patient outcomes than D-F and ESC scores.
- Integrating physician judgment into risk prediction models may enhance the management of patients with stable chest pain.
Objective:
To evaluate informal physician judgement versus pretest probability scores in estimating risk in patients with suspected coronary artery disease (CAD).
Methods:
We included 4533 patients from the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial. Physicians categorised a priori the pretest probability of obstructive CAD (≥70% or ≥50% left main); Diamond-Forrester (D-F) and European Society of Cardiology (ESC) pretest probability estimates were calculated. Agreement was calculated using the κ statistic; logistic regression evaluated estimates of pretest CAD probability and actual CAD (as determined by CT coronary angiography), and clinical outcomes were modelled using Cox proportional hazard models.
Results:
Physician estimates agreed poorly with D-F (κ 0.16; 95% CI 0.14 to 0.18) and ESC (κ 0.04; 95% CI 0.02 to 0.05). Actual obstructive CAD was significantly more prevalent in both the high-likelihood (OR 3.30; 95% CI 2.30 to 4.74) and the intermediate-likelihood (OR 1.43; 95% CI 1.16 to 1.76) physician-estimated groups versus the low-likelihood group; ESC similarly differentiated between the three groups (OR 9.07; 95% CI 2.87 to 28.70; and OR 3.87; 95% CI 1.22 to 12.28). However, using D-F, only the high-probability group differed (OR 2.49; 95% CI 1.74 to 3.54). Only physician estimates were associated with a higher incidence of adjusted death/myocardial infarction/unstable angina hospitalisation in the high-probability versus low-probability group (HR 2.68; 95% CI 1.52 to 4.74); neither pretest probability score provided prognostic information.
Conclusions:
Compared with D-F and ESC estimates, physician judgement more accurately identified obstructive CAD and worse patient outcomes. Integrating physician judgement may improve risk prediction for patients with stable chest pain.
Trial Registration Number:
NCT01174550.
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