Physician judgement in predicting obstructive coronary artery disease and adverse events in chest pain patients.

To evaluate informal physician judgement versus pretest probability scores in estimating risk in patients with suspected coronary artery disease (CAD). We included 4533 patients from the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial. Physicians categorised a priori the pretest probability of obstructive CAD (≥70% or ≥50% left main); Diamond-Forrester (D-F) and European Society of Cardiology (ESC) pretest probability estimates were calculated. Agreement was calculated using the κ statistic; logistic regression evaluated estimates of pretest CAD probability and actual CAD (as determined by CT coronary angiography), and clinical outcomes were modelled using Cox proportional hazard models. Physician estimates agreed poorly with D-F (κ 0.16; 95% CI 0.14 to 0.18) and ESC (κ 0.04; 95% CI 0.02 to 0.05). Actual obstructive CAD was significantly more prevalent in both the high-likelihood (OR 3.30; 95% CI 2.30 to 4.74) and the intermediate-likelihood (OR 1.43; 95% CI 1.16 to 1.76) physician-estimated groups versus the low-likelihood group; ESC similarly differentiated between the three groups (OR 9.07; 95% CI 2.87 to 28.70; and OR 3.87; 95% CI 1.22 to 12.28). However, using D-F, only the high-probability group differed (OR 2.49; 95% CI 1.74 to 3.54). Only physician estimates were associated with a higher incidence of adjusted death/myocardial infarction/unstable angina hospitalisation in the high-probability versus low-probability group (HR 2.68; 95% CI 1.52 to 4.74); neither pretest probability score provided prognostic information. Compared with D-F and ESC estimates, physician judgement more accurately identified obstructive CAD and worse patient outcomes. Integrating physician judgement may improve risk prediction for patients with stable chest pain. NCT01174550.

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Competing interests: CBF: Consulting fees/honoraria from Bayer, Novo Nordisk, Sanofi, Boehringer Ingelheim, Pfizer; research support from Bayer; Steering Committee service for HeartFlow. DM: Consultant fees/honoraria from Medtronic; research support from AGA Medical, AstraZeneca, Bayer Healthcare Pharmaceuticals, BMS, Eli Lilly, Gilead, Merck & Co., Inc. UH: Research support from HeartFlow. MRP: Consultant fees/honoraria from Bayer Healthcare, Genzyme, Medscape - theheart.org, Merck; research support from AHRQ, AstraZeneca, Jansen, Johnson & Johnson, Maquet, National Heart Lung and Blood Institute, PCORI. PD: Research support from HeartFlow. No other disclosures were reported.