Implications of Alterations in Pre-test Probability in the 2019 Update of ESC Guidelines for Chronic Coronary Syndromes on Diagnostic Accuracy of Pharmacological Stress-Echocardiography: A Retrospective Cohort Study

Abstract

BACKGROUND: With the 2019 update of European Society of Cardiology (ESC) guidelines for chronic coronary syndromes, the pre-test probabilities (PTPs) based on age, sex, and symptoms have undergone major revisions. We aimed to determine implications of these alterations on diagnostic accuracy of dobutamine stress echocardiography (DSE). METHODS: We retrospectively included consecutive patients undergoing pharmacological stress-echocardiography for evaluation of suspected obstructive coronary artery disease. DSE was performed as non-invasive imaging test and was indicated by individual treating physician's decision. Sensitivity, specificity, positive and negative predictive value as well as accuracy were assessed for detection of obstructive coronary artery disease, defined as revascularization therapy following DSE. RESULTS: We included 206 patients (mean age 63.2 ± 12.4 years, 59.7% male). 51% of the cohort had a PTP of < 15% according to both scores. 9.2% of patients with PTP < 15% according to the original Diamond and Forrester score had a PTP > 15% according to 2019 ESC guidelines, predominantly due to the accountancy of dyspnea. In contrast, 13.6% of patient had a PTP ≥ 15% according to the original Diamond and Forrester score, while PTP was assessed below this threshold by updated guidelines. The differences in patient selection according to updated guidelines did not alter the diagnostic accuracy of DSE (68% for both). CONCLUSIONS: Changes in assessment of PTP according to updated ESC guidelines from 2019 led to a relevant reclassification of patients with suspected coronary artery disease, ultimately changing the group of patients appropriate for DSE for evaluation of myocardial ischemia. Comparing the diagnostic performance in appropriate PTP groups, however, led to similar results.