Validation of European Society of Cardiology pre-test probabilities for obstructive coronary artery disease in suspected stable angina

AIMS: To assess contemporary pre-test probability estimates for obstructive coronary artery disease in patients with stable chest pain.

METHODS AND RESULTS: In a substudy of a multicentre randomised controlled trial, we compared 2019 European Society of Cardiology (ESC)-endorsed pre-test probabilities with observed prevalence of obstructive coronary artery disease on computed tomography coronary angiography (CTCA). We assessed associations between pre-test probability, 5-year coronary heart disease death or non-fatal myocardial infarction and study intervention (standard care versus CTCA).The study population consisted of 3755 patients (30-75 years, 46% women) with a median pre-test probability of 11% of whom 1622 (43%) had a pre-test probability >15%. In those who underwent CTCA (n = 1613), the prevalence of obstructive disease was 22%. When divided into deciles of pre-test probability, the observed disease prevalence was similar but higher than the corresponding median pre-test probability (median difference 2.3 [1.3-5.6]%). There were more clinical events in patients with a pre-test probability >15% compared to those at 5-15% and <5% (4.1%, 1.5% and 1.4% respectively, p < 0.001). Across the total cohort, fewer clinical events occurred in patients who underwent CTCA, with the greatest difference in those with a pre-test probability >15% (2.8% vs 5.3%, log rank p = 0.01), although this interaction was not statistically significant on multivariable modelling.

CONCLUSION: The updated 2019 ESC guideline pre-test probability recommendations tended to slightly underestimate disease prevalence in our cohort. Pre-test probability is a powerful predictor of future coronary events and helps select those who may derive the greatest absolute benefit from CTCA.