Accuracy of Diamond-Forrester estimates for CAD declining, says JAMA study
USA: The accuracy of Diamond-Forrester estimates of pretest probability of coronary artery disease (CAD) are declining, according to the authors view point, published in the journal JAMA Internal Medicine.
According to the authors, the European CAD Consortium estimation method is the most reliable.
The Diamond-Forrester estimates were developed in the late 1970s based on a small group of highly selected patients, most of whom were men with an average age <50 years. Since then, the epidemiology of CAD has changed considerably. Now, the patients tend to be older and there are more women.
The consortium estimates are based on data for 2260 patients from 14 catheterization laboratories and yield better classification of women, usually downward relative to Diamond-Forrester classification.
A 2019 study that compared various risk scores found that the CAD Consortium clinical score performed best among the 3 options (updated Diamond-Forrester, CONFIRM risk score, consortium score), although not perfectly.
This view point by Raymond J. Gibbons and Todd D. Miller from Mayo Clinic, Rochester, Minnesota, summarizes their assessment of the evidence for a temporal decline in the accuracy of Diamond-Forrester estimates, indicates which current method for ePTP is most reliable, and explains why ePTP remains clinically useful.
Key points:
- The authors endorse consortium estimates as most reliable and say adding more risk factors "does not seem justified."
- Use of consortium estimates means clinicians also have to reconsider how they evaluate CAD in women, who have less obstructive disease when younger than 70 years.
- The estimate also can predict outcomes, the authors write—specifically myocardial infarction and death—but this applicability is underappreciated.
- They conclude that because CAD is decreasing, less testing overall is warranted.
- Estimates <15%, they say, do not require cardiac testing, in keeping with 2019 European Society of Cardiology guidelines.
Reference:
"Declining Accuracy of the Traditional Diamond-Forrester Estimates of Pretest Probability of Coronary Artery Disease: Time for New Methods," is published in the journal JAMA Internal Medicine.
DOI: https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2777340
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