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Validation and update of the minimal risk tool in patients suspected of chronic coronary syndrome

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Abstract

Risk stratification in patients with suspected coronary artery disease (CAD) is important. Recently, the minimal-risk-tool (MRT) was developed to identify individuals with low CAD risk despite symptoms in order to avoid unnecessary testing. We aimed to validate and update the MRT-model in a contemporary cohort. The Dan-NICAD trial cohort, consisting of 1675 consecutive patients referred for coronary computed tomography angiography (CTA), was used to calculate the MRT-score based on the published fitted variable coefficients from the PROMISE and SCOT-HEART trials. Minimal risk was defined as zero calcium score, no coronary atherosclerosis at coronary CTA, and no cardiovascular events in the follow-up period. We tested an updated MRT-model by pooling the fitted variable coefficients from all three trials. A total of 1544 patients fulfilling the inclusion criteria were followed for 3.1 [2.7–3.4] years. In 710 (46%) patients, the criteria for minimal risk were fulfilled. Despite substantial coefficient variation, the MRTs based on the PROMISE, the SCOT-HEART and the updated MRT variables showed similar moderate to high discriminative performance for minimal risk estimation. Although all three models tended to underestimate minimal risk, the updated MRT had the best performance. Using a 75% minimal risk cut-off, the updated MRT showed a sensitivity of 11.6% (95% CI 9.3–14.2%) and specificity of 99.3% (95% CI 98.6–99.8%). An updated MRT model based on three large studies increased calibration compared to the existing MRT models, whereas discrimination was similar despite substantial coefficient variation. The updated MRT might supplement currently recommended pre-test probability models.

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Abbreviations

PTP:

Pre-test probability

CAD:

Coronary artery disease

ESC:

European Society of Cardiology

PROMISE:

Prospective Multicenter Imaging Study for Evaluation of Chest Pain

SCOT-HEART:

Scottish COmputed Tomography of the HEART trial

MRT:

Minimal risk tool

Dan-NICAD:

Danish study of Non-Invasive testing in Coronary Artery Disease

CTA:

Computed tomography angiography

HDL:

High-density lipoprotein

AUC:

Area under the receiver-operator curve

PPV:

Positive predictive values

NPV:

Negative predictive values

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Acknowledgements

The study was supported by The Danish Heart Foundation (Grant No. 15-R99-A5837-22920) and the Health Research Fund of Central Denmark Region.

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Authors and Affiliations

  1. Department of Cardiology, Hospital Unit West, Gødstrup Hospital, Gl. Landevej 61, 7400, Herning, Denmark

    Laust Dupont Rasmussen, Louise Nissen, Lars Lyhne Knudsen, Lene Helleskov Madsen, Morten Bøttcher & Simon Winther

  2. Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Bouleevard 99, 8200, Aarhus N, Denmark

    Jelmer Westra, Niels Ramsing Holm, Evald Høj Christiansen & Hans Erik Bøtker

Authors
  1. Laust Dupont Rasmussen
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  2. Louise Nissen
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  3. Jelmer Westra
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  4. Lars Lyhne Knudsen
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  9. Morten Bøttcher
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  10. Simon Winther
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Correspondence to Laust Dupont Rasmussen.

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Conflict of interest

MOB is an advisory board member of Novo Nordisk, Bayer, ACARIX, SANOFI and Astra Zeneca. SW received support from Acarix in the form of an institutional research Grant. All other authors have nothing to declare.

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Laust Dupont Rasmussen, Louise Nissen, Jelmer Westra, Lars Lyhne Knudsen, Lene Helleskov Madsen, Niels Ramsing Holm, Evald Høj Christiansen, Hans Erik Bøtker, Morten Bøttcher, and Simon Winther authors takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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Rasmussen, L.D., Nissen, L., Westra, J. et al. Validation and update of the minimal risk tool in patients suspected of chronic coronary syndrome. Int J Cardiovasc Imaging 37, 699–706 (2021). https://doi.org/10.1007/s10554-020-01982-7

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  • DOI: https://doi.org/10.1007/s10554-020-01982-7

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