Comparison of the Diamond-Forrester Method and Duke Clinical Score to Predict Obstructive Coronary Artery Disease by Computed Tomographic Angiography

Published:January 12, 2012DOI:
      We sought to evaluate the ability of the Diamond and Forrester method (DFM) and the Duke Clinical Score (DCS) to predict obstructive coronary artery disease (CAD) on coronary computed tomographic angiography (CCTA) and the effect of these different risk scores on the appropriateness level using the 2010 Appropriate Use Criteria. Consecutive symptomatic patients who underwent CCTA for evaluation of CAD (n = 114) were classified as having a low, intermediate, or high pretest probability using the DFM and DCS. Using the Appropriate Use Criteria, the indications for CCTA were classified according to the pretest probability and previous testing. The CCTA results were classified as revealing obstructive (≥70% stenosis), nonobstructive (<70%), or no CAD. When the patients' risk was classified using the DFM, 18% were low, 65% intermediate, and 17% high risk. When using the DCS, 53% of patients had a reclassification of their risk, most of whom changed from intermediate to either low or high risk (50% low, 19% intermediate, 35% high risk). The net reclassification improvement for the prediction of obstructive CAD was 51% (p = 0.01). Of the 37 patients who were reclassified as low risk, 36 (97%) lacked obstructive CAD. Appropriateness for CCTA was reclassified for 13% of patients when using the DCS instead of the DFM, and the number of appropriate examinations was significantly fewer (68% vs 55%, p <0.001). In conclusion, reclassification of risk using the DCS instead of the DFM resulted in improved prediction of obstructive CAD on CCTA, especially in low-risk patients. More patients were categorized as having a high pretest probability of CAD, resulting in reclassification of their examination indications as uncertain or inappropriate. These results identify the need for improved pretest risk scores for noninvasive tests such as CCTA and suggest that the method of risk assessment could have important implications for patient selection and quality assurance programs.
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        • Diamond G.A.
        • Forrester J.S.
        Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease.
        N Engl J Med. 1979; 300: 1350-1358
        • Pryor D.B.
        • Harrell Jr, F.E.
        • Lee K.L.
        • Califf R.M.
        Rosati RA Estimating the likelihood of significant coronary artery disease.
        Am J Med. 1983; 75: 771-780
        • Taylor A.J.
        • Cerqueira M.
        • Hodgson J.M.
        • Mark D.
        • Min J.
        • O'Gara P.
        • Rubin G.D.
        • Kramer C.M.
        • Berman D.
        • Brown A.
        • Chaudhry F.A.
        • Cury R.C.
        • Desai M.Y.
        • Einstein A.J.
        • Gomes A.S.
        • Harrington R.
        • Hoffmann U.
        • Khare R.
        • Lesser J.
        • McGann C.
        • Rosenberg A.
        • Schwartz R.
        • Shelton M.
        • Smetana G.W.
        • Smith Jr, S.C.
        ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance.
        J Am Coll Cardiol. 2010; 56: 1864-1894
        • Hendel R.C.
        • Patel M.R.
        • Kramer C.M.
        • Poon M.
        • Hendel R.C.
        • Carr J.C.
        • Gerstad N.A.
        • Gillam L.D.
        • Hodgson J.M.
        • Kim R.J.
        • Kramer C.M.
        • Lesser J.R.
        • Martin E.T.
        • Messer J.V.
        • Redberg R.F.
        • Rubin G.D.
        • Rumsfeld J.S.
        • Taylor A.J.
        • Weigold W.G.
        • Woodard P.K.
        • Brindis R.G.
        • Hendel R.C.
        • Douglas P.S.
        • Peterson E.D.
        • Wolk M.J.
        • Allen J.M.
        • Patel M.R.
        ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a report of the American College of Cardiology Foundation quality strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology.
        J Am Coll Cardiol. 2006; 48: 1475-1497
        • Meijboom W.B.
        • van Mieghem C.A.
        • Mollet N.R.
        • Pugliese F.
        • Weustink A.C.
        • van Pelt N.
        • Cademartiri F.
        • Nieman K.
        • Boersma E.
        • de Jaegere P.
        • Krestin G.P.
        • de Feyter P.J.
        64-Slice computed tomography coronary angiography in patients with high, intermediate, or low pretest probability of significant coronary artery disease.
        J Am Coll Cardiol. 2007; 50: 1469-1475
        • Min J.K.
        • Shaw L.J.
        • Devereux R.B.
        • Okin P.M.
        • Weinsaft J.W.
        • Russo D.J.
        • Lippolis N.J.
        • Berman D.S.
        • Callister T.Q.
        Prognostic value of multidetector coronary computed tomographic angiography for prediction of all-cause mortality.
        J Am Coll Cardiol. 2007; 50: 1161-1170
        • Maffei E.
        • Seitun S.
        • Martini C.
        • Palumbo A.
        • Tarantini G.
        • Berti E.
        • Grilli R.
        • Tedeschi C.
        • Messalli G.
        • Guaricci A.
        • Weustink A.C.
        • Mollet N.R.
        • Cademartiri F.
        CT coronary angiography and exercise ECG in a population with chest pain and low-to-intermediate pre-test likelihood of coronary artery disease.
        Heart. 2010; 96: 1973-1979
        • van Werkhoven J.M.
        • Gaemperli O.
        • Schuijf J.D.
        • Jukema J.W.
        • Kroft L.J.
        • Leschka S.
        • Alkadhi H.
        • Valenta I.
        • Pundziute G.
        • de Roos A.
        • van der Wall E.E.
        • Kaufmann P.A.
        • Bax J.J.
        Multislice computed tomography coronary angiography for risk stratification in patients with an intermediate pretest likelihood.
        Heart. 2009; 95: 1607-1611
        • Chow B.J.
        • Abraham A.
        • Wells G.A.
        • Chen L.
        • Ruddy T.D.
        • Yam Y.
        • Govas N.
        • Galbraith P.D.
        • Dennie C.
        • Beanlands R.S.
        Diagnostic accuracy and impact of computed tomographic coronary angiography on utilization of invasive coronary angiography.
        Circ Cardiovasc Imaging. 2009; 2: 16-23
        • Leber A.W.
        • Johnson T.
        • Becker A.
        • von Ziegler F.
        • Tittus J.
        • Nikolaou K.
        • Reiser M.
        • Steinbeck G.
        • Becker C.R.
        • Knez A.
        Diagnostic accuracy of dual-source multi-slice CT-coronary angiography in patients with an intermediate pretest likelihood for coronary artery disease.
        Eur Heart J. 2007; 28: 2354-2360
        • Husmann L.
        • Schepis T.
        • Scheffel H.
        • Gaemperli O.
        • Leschka S.
        • Valenta I.
        • Koepfli P.
        • Desbiolles L.
        • Stolzmann P.
        • Marincek B.
        • Alkadhi H.
        • Kaufmann P.A.
        Comparison of diagnostic accuracy of 64-slice computed tomography coronary angiography in patients with low, intermediate, and high cardiovascular risk.
        Acad Radiol. 2008; 15: 452-461
        • Cheng V.
        • Dunning A.
        • Achenbach S.
        • Al-Mallah M.
        • Budoff M.J.
        • Callister T.Q.
        • Chang H.
        • Chow B.
        • Delago A.
        • Hadamitzky M.
        • Hausleiter J.
        • Karlsberg R.P.
        • Kaufmann P.
        • Lin F.Y.
        • Min J.K.
        • Nasir K.
        • Shaw L.J.
        Abstract 12100: marked overestimation of obstructive coronary artery disease probability by the Diamond-Forrester classification in symptomatic patients undergoing coronary CT angiography: results from the multinational CONFIRM Registry (Coronary CT Angiographic Evaluation For Clinical Outcomes: An International Multicenter Registry).
        Circulation. 2010; 122 (BD): 12100
        • Genders T.S.
        • Steyerberg E.W.
        • Alkadhi H.
        • Leschka S.
        • Desbiolles L.
        • Nieman K.
        • Galema T.W.
        • Meijboom W.B.
        • Mollet N.R.
        • de Feyter P.J.
        • Cademartiri F.
        • Maffei E.
        • Dewey M.
        • Zimmermann E.
        • Laule M.
        • Pugliese F.
        • Barbagallo R.
        • Sinitsyn V.
        • Bogaert J.
        • Goetschalckx K.
        • Schoepf U.J.
        • Rowe G.W.
        • Schuijf J.D.
        • Bax J.J.
        • de Graaf F.R.
        • Knuuti J.
        • Kajander S.
        • van Mieghem C.A.
        • Meijs M.F.
        • Cramer M.J.
        • Gopalan D.
        • Feuchtner G.
        • Friedrich G.
        • Krestin G.P.
        • Hunink M.G.
        A clinical prediction rule for the diagnosis of coronary artery disease: validation, updating, and extension.
        Eur Heart J. 2011; 32: 1316-1330
        • Murphy M.K.
        • Brady T.J.
        • Nasir K.
        • Gazelle G.S.
        • Bamberg F.
        • Truong Q.A.
        • Mamuya W.S.
        • Abbara S.
        • Lee T.H.
        • Blankstein R.
        Appropriateness and utilization of cardiac CT: implications for development of future criteria.
        J Nucl Cardiol. 2010; 17: 881-889
        • Pencina M.J.
        • D'Agostino Sr, R.B.
        • D'Agostino Jr, R.B.
        • Vasan R.S.
        Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond.
        Stat Med. 2008; 27: 157-172
        • Jensen J.M.
        • Ovrehus K.A.
        • Nielsen L.H.
        • Jensen J.K.
        • Larsen H.M.
        • Norgaard B.L.
        Paradigm of pretest risk stratification before coronary computed tomography.
        J Cardiovasc Comput Tomogr. 2009; 3: 386-391
        • Hulten E.A.
        • Carbonaro S.
        • Petrillo S.P.
        • Mitchell J.D.
        • Villines T.C.
        Prognostic value of cardiac computed tomography angiography: a systematic review and meta-analysis.
        J Am Coll Cardiol. 2011; 57: 1237-1247
        • Blankstein R.
        • Di Carli M.F.
        Integration of coronary anatomy and myocardial perfusion imaging.
        Nat Rev Cardiol. 2010; 7: 226-236
        • Ayyad A.E.
        • Cole J.
        • Syed A.
        • Desai M.Y.
        • Halliburton S.
        • Schoenhagen P.
        • Flamm S.D.
        • Sola S.
        Temporal trends in utilization of cardiac computed tomography.
        J Cardiovasc Comput Tomogr. 2009; 3: 16-21