Background: Non-invasive functional imaging (NIFI) can accurately rule out hemodynamically significant coronary artery disease (CAD) and can act as a gatekeeper for invasive revascularization.
Purpose: To analyze an integrated approach by a clinical decision support system (DSS) vs standard care (STD) in patients (pts) at intermediate pre-test likelihood of CAD referred for stable chest pain evaluation.
Methods: 498 pts (303 males and 195 females, age 56±6 years) were referred for stable chest pain evaluation over a 16 month period in three different hospitals. A computerized browsing automated DSS and a human cardiologist STD were applied during the same day visit. Pre-test likelihood of CAD was based on Clinical score + coronary artery calcium scoring (CACS). Significant CAD (>50% coronary stenosis) criteria were applied in all pts by computerized tomography coronary angiography (CTCA).
Results: Pre-test likelihood of CAD is shown in the Table. 281 (56.4%) pts were classified as “No further test (NFT)”, 182 (36.5%) “Ex test (ET)/Functional Imaging (FI)” and only 34 (6.8%) “CTCA” and 1 (0.3%) “(ICA)” by DSS. Of note, DSS “ET/FI” + “NFT” and STD “ET/FI” + “NFT” + “CTA” subgroups identified respectively 391 (78.5%) and 372 (74.6%) pts free of significant CAD or inducible myocardial ischemia (p=0.3). The diagnostic accuracy of DSS “ET/FI” + “NFT” (without “CTA” data) class resulted 92.5%.
Conclusions: The data suggests that direct visualization of the coronary arteries did not add any value for the diagnosis of CAD. However, it should be noted that “No further test +/− functional imaging” class is a powerful negative predictive value for significant CAD. Therefore DSS could represent a valid solution for prescribing the correct test for risk stratification at point-of-care.