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Sex Differences in Two International Guidelines for Assessing Obstructive Coronary Artery Disease in Symptomatic
Yahang Tan1, Zhe Wang1, Qian Xin2
1Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, 100020 Beijing, China.
Insights
The European Society of Cardiology (ESC) guidelines more accurately assess chest pain risk in outpatients than National Institute for Health and Care Excellence (NICE) guidelines. ESC guidelines reduce unnecessary testing in women and improve appropriate testing in men.
Area of Science:
- Cardiology
- Medical Guidelines
- Diagnostic Testing
Background:
- Coronary artery disease (CAD) prevalence is lower in women.
- Noninvasive testing may not benefit low-risk individuals.
- Current guidelines for assessing chest pain outpatients differ by sex.
Purpose of the Study:
- Compare the performance of NICE and ESC guidelines for chest pain outpatients.
- Evaluate sex-specific differences in guideline application.
- Assess the accuracy of risk stratification for coronary artery disease.
Main Methods:
- Retrospective study of 542 outpatients referred for coronary computed tomography angiography (CCTA).
- Risk assessment using 2016 NICE and 2019 ESC guidelines.
- Classification into low and high-risk groups.
- Net reclassification improvement (NRI) used to compare guideline performance.
Main Results:
- Coronary artery disease (CAD) prevalence was 27%.
- ESC guidelines demonstrated higher sensitivity, specificity, and positive predictive value compared to NICE.
- ESC guidelines showed a positive NRI of 30.32% compared to NICE.
- ESC guidelines classified more women (55.56%) than men (28.14%) as low-risk.
Conclusions:
- ESC guidelines provide more accurate risk assessment for chest pain outpatients than NICE guidelines.
- Applying ESC guidelines can decrease inappropriate testing in women.
- ESC guidelines can increase appropriate noninvasive testing in men.
Background:
Low-risk individuals are unlikely to benefit from noninvasive testing, and women tend to have a lower prevalence of coronary artery disease (CAD). This study compared the performance of two current guidelines that differ by sex to assess s a'q's't chest pain outpatients, including symptom-based (2016 National Institute for Health and Care Excellence, NICE) and risk-based strategies (2019 European Society of Cardiology, ESC).
Methods:
A total of 542 outpatients referred for coronary computed tomography angiography (CCTA) at a single-centre were retrospectively included in this study. A risk assessment was calculated for each outpatient according to the two guidelines. Patients were classified into low and high-risk groups according to each strategy. The presence of coronary artery disease was the endpoint. Net reclassification improvement (NRI) was used to assess the performance of the two strategies.
Results:
The prevalence of CAD was 27%. The sensitivity, specificity, positive predictive value and negative predictive value for ESC and NICE were 90.4%, 54.3%, 42.2%, 93.9% and 78.8%, 35.6%, 31.1% and 82.0% respectively. Compare to NICE, the NRI for ESC were 30.32%. The ESC guidelines classified 55.56% of women and 28.14% of men into the low-risk group. The ESC guidelines had a higher predictive value for coronary artery disease compared to the NICE guidelines, with a positive NRI in men (15.55%) and women (34.46%) respectively.
Conclusions:
The ESC guidelines offered a more accurate calculation of risk assessment than the NICE guidelines. Patient sex influenced applying the recent ESC guidelines, which would result in a significant decrease in inappropriate testing of women but an increase in appropriate noninvasive testing of men.
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