Standard clinical and stress electrocardiogram variables to exclude left main and left main-equivalent disease: the
Marco De Carlo1, Marco Andrea Malanima2, Laura Baglietto2
1Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, Pisa University Hospital, Pisa, Italy.
Insights
A new model using clinical and ECG stress testing (EST) effectively excludes left main coronary artery disease (LMCAD) in chronic coronary syndrome (CCS) patients. This allows for safe initial non-invasive management, potentially improving access to care where advanced imaging is limited.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Clinical Decision Making
Background:
- Left main (LM) coronary artery disease (CAD) exclusion is crucial for managing chronic coronary syndrome (CCS).
- A reliable non-invasive method to exclude LMCAD or LMCAD-equivalent is needed to guide initial patient management.
- Current diagnostic strategies may be limited by accessibility to advanced imaging modalities.
Purpose of the Study:
- To assess the diagnostic utility of a model combining clinical and ECG stress testing (EST) variables.
- To determine the effectiveness of this model in excluding LMCAD/LMCAD-equivalent in CCS patients.
- To evaluate the potential for expanding non-invasive management strategies.
Main Methods:
- A multicentre case-control study involving CCS patients undergoing coronary angiography (CAG) post-maximal EST.
- Cases defined by significant LM stenosis (≥50%) or proximal LAD/LCx stenosis (≥70%); controls without these findings, matched 1:3.
- A logistic regression risk model was developed and validated internally and externally.
Main Results:
- The study included 335 cases and 797 controls, with a model Area Under the Curve (AUC) of 0.78.
- With a 5% LMCAD prevalence and 1:100 misclassification cost ratio, the Negative Predictive Value (NPV) was 98.2%.
- The model allows safely avoiding CAG in 41% of patients, missing one LMCAD diagnosis for every 58 CAGs spared.
Conclusions:
- A model integrating clinical and EST parameters can exclude LMCAD/LMCAD-equivalent with high NPV in CCS patients.
- This approach supports initial non-invasive management for most exercise-capable patients.
- The method is particularly valuable in resource-limited settings lacking widespread computed tomography coronary angiography access.
Background And Aims:
A simple diagnostic method able to reliably exclude left main (LM) coronary artery disease (CAD) or LMCAD-equivalent would expand implementation of an initial non-invasive strategy in patients with chronic coronary syndrome (CCS). This study assessed the diagnostic utility of an approach using clinical and ECG stress testing (EST) variables in excluding LMCAD/LMCAD-equivalent in CCS patients.
Methods:
In a multicentre case-control study, CCS patients undergoing invasive coronary angiography (CAG) after a maximal EST were evaluated. Cases were patients with angiographic ≥ 50% LM stenosis or ≥70% stenosis of both proximal left anterior descending and proximal circumflex arteries, matched with similar patients without them (controls) in a 1:3 ratio. A risk model developed through logistic regression was internally and externally validated.
Results:
Three hundred and thirty-five cases were matched with 797 controls. The model area under the curve (AUC) was .78. Assuming LMCAD prevalence of 5% and a misclassification cost ratio of 1:100 (ratio of cost of performing CAG in a control to cost of not performing CAG in a case), negative predictive value was 98.2%. Thus, CAG could be safely avoided in 41% of patients, missing one LMCAD/LMCAD-equivalent diagnosis for every 58 CAGs safely spared in patients without them.
Conclusions:
Among CCS patients, LMCAD/LMCAD-equivalent can be excluded with high negative predictive value through a model based on clinical and EST parameters, allowing initial non-invasive management of most patients able to exercise. This approach is potentially useful particularly in communities where access to computed tomography coronary angiography is limited.
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