在中国稳定性胸痛患者中利用冠脉CTA对冠心病验前概率模型进行验证和比较
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摘要
目的在行冠状动脉CT血管造影(CCTA)检查的中国人群中对升级的Diamond–Forrester模型(UDFM)和杜克临床评分(DCS)进行验证和比较。方法收集2015年12月—2017年12月天津市胸科医院共5 743例因稳定性胸痛行CCTA检查的患者资料。冠心病定义为经CCTA确认至少有1个节段冠脉血管直径狭窄超过50%。每例患者的验前概率分别根据UFDM和DCS计算。采用受试者工作特征曲线下面积(AUC)、净重分类改善(NRI)和Hosmer–Lemeshow拟合优度统计量(H-Lχ~2)等指标对模型的评估准确性进行验证和比较。结果共有1 872(32%)例患者经CCTA检查确证为冠心病。DCS(AUC=0.772,95%CI:0.759～0.786)和UDFM(AUC=0.765,95%CI:0.751～0.779)差异无统计学意义(P=0.068)。DCS相对于UDFM有更好的分类能力(NRI=26.20%,P<0.001)。UDFM(H-Lχ~2=137.823,P<0.01)和DCS(H-Lχ~2=156.704,P<0.01)的校准能力均较差,均高估了实际患病率。结论与UDFM相比,DCS能更好地在行CCTA检查的中国人群中估算冠心病的验前概率,但两者均高估了冠心病的实际患病率。
Objective To compare the performance of updated Diamond–Forrester method(UDFM) and Duke clinical score(DCS) in a Chinese population referred to coronary computed tomography angiography(CCTA).MethodsA total of 5 743 consecutive patients with suspected coronary artery disease(CAD) who underwent CCTA for stable chest pain were collected in Tianjin Chest Hospital from December 2015 to December 2017. CAD was defined as stenosis ≥50% in diameter at least one segment of the coronary artery by CCTA. For each patient, pretest probability(PTP) of CAD was estimated according to UDFM and DCS, respectively. Area under the receiver operating characteristic curve(AUC), net reclassification improvement(NRI) and Hosmer–Lemeshow goodness-of-fit statistic(H-Lχ~2) were assessed to validate and compare the two models.Results Overall, 1 872(32%) patients were diagnosed as CAD by coronary CTA examination. There were no significant differences between DCS(AUC=0.772, 95%CI: 0.759-0.786) and UDFM(AUC=0.765,95%CI:0.751-0.779, P=0.068). DCS demonstrated the improved classification over UDFM through the positive NRI(26.20%, P<0.001). The calibration of UDFM(H-Lχ~2=137.823) and DCS(H-Lχ~2=156.704) was both unsatisfactory(P<0.01), and both overestimated the actual prevalence of CAD.Conclusion Compared to UDFM, DCS is superior for estimating the PTP of CAD in Chinese population referred for CCTA, but both overestimate the actual prevalence of CAD.
Objective To compare the performance of updated Diamond–Forrester method(UDFM) and Duke clinical score(DCS) in a Chinese population referred to coronary computed tomography angiography(CCTA).MethodsA total of 5 743 consecutive patients with suspected coronary artery disease(CAD) who underwent CCTA for stable chest pain were collected in Tianjin Chest Hospital from December 2015 to December 2017. CAD was defined as stenosis ≥50% in diameter at least one segment of the coronary artery by CCTA. For each patient, pretest probability(PTP) of CAD was estimated according to UDFM and DCS, respectively. Area under the receiver operating characteristic curve(AUC), net reclassification improvement(NRI) and Hosmer–Lemeshow goodness-of-fit statistic(H-Lχ~2) were assessed to validate and compare the two models.Results Overall, 1 872(32%) patients were diagnosed as CAD by coronary CTA examination. There were no significant differences between DCS(AUC=0.772, 95%CI: 0.759-0.786) and UDFM(AUC=0.765,95%CI:0.751-0.779, P=0.068). DCS demonstrated the improved classification over UDFM through the positive NRI(26.20%, P<0.001). The calibration of UDFM(H-Lχ~2=137.823) and DCS(H-Lχ~2=156.704) was both unsatisfactory(P<0.01), and both overestimated the actual prevalence of CAD.Conclusion Compared to UDFM, DCS is superior for estimating the PTP of CAD in Chinese population referred for CCTA, but both overestimate the actual prevalence of CAD.
引文
[1]Fihn SD,Blankenship JC,Alexander KP,et al.2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease:a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines,and the American Association for Thoracic Surgery,Preventive Cardiovascular Nurses Association,Society for Cardiovascular Angiography and Interventions,and Society of Thoracic Surgeons[J].J Am Coll Cardiol,2014,64(18):1929-1949.doi:10.1016/j.jacc.2014.07.017.
[2]Task Force Members,Montalescot G,Sechtem U,et al.2013 ESCguidelines on the management of stable coronary artery disease:the Task Force on the management of stable coronary artery disease of the European Society of Cardiology[J].Eur Heart J,2013,34(38):2949-3003.doi:10.1093/eurheartj/eht296.
[3]Wolk MJ,Bailey SR,Doherty JU,et al.ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease:a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force,American Heart Association,American Society of Echocardiography,American Society of Nuclear Cardiology,Heart Failure Society of America,Heart Rhythm Society,Society for Cardiovascular Angiography and Interventions,Society of Cardiovascular Computed Tomography,Society for Cardiovascular Magnetic Resonance,and Society of Thoracic Surgeons[J].J Am Coll Cardiol,2014,63(4):380-406.doi:10.1016/j.jacc.2013.11.009.
[4]Pryor DB,Shaw L,McCANTS CB,et al.Value of the history and physical in identifying patients at increased risk for coronary artery disease[J].Ann Intern Med,1993,118(2):81-90.
[5]Genders TS,Steyerberg EW,Alkadhi H,et al.A clinical prediction rule for the diagnosis of coronary artery disease:validation,updating,and extension[J].Eur Heart J,2011,32(11):1316-1330.doi:10.1093/eurheartj/ehr014.
[6]Jensen JM,Voss M,Hansen VB,et al.Risk stratification of patients suspected of coronary artery disease:comparison of five different models[J].Atherosclerosis,2012,220(2):557-562.doi:10.1016/j.atherosclerosis.2011.11.027.
[7]Bittencourt MS,Hulten E,Polonsky TS,et al.European Society of Cardiology-Recommended Coronary Artery Disease Consortium Pretest Probability Scores More Accurately Predict Obstructive Coronary Disease and Cardiovascular Events Than the Diamond and Forrester Score:The Partners Registry[J].Circulation,2016,134(3):201-211.doi:10.1161/circulationaha.116.023396.
[8]Diamond GA.Right answer,wrong question:on the clinical relevance of the cardiovascular history[J].Circulation,2011,124(22):2377-2379.doi:10.1161/CIRCULATIONAHA.111.068718.
[9]Kumamaru KK,Arai T,Morita H,et al.Overestimation of pretest probability of coronary artery disease by Duke clinical score in patients undergoing coronary CT angiography in a Japanese population[J].J Cardiovasc Comput Tomogr,2014,8(3):198-204.doi:10.1016/j.jcct.2014.02.002.
[10]Cury RC,Abbara S,Achenbach S,et al.CAD-RADS(TM)Coronary Artery Disease-Reporting and Data System.An expert consensus document of the Society of Cardiovascular Computed Tomography(SCCT),the American College of Radiology(ACR)and the North American Society for Cardiovascular Imaging(NASCI).Endorsed by the American College of Cardiology[J].JCardiovasc Comput Tomogr,2016,10(4):269-281.doi:10.1016/j.jcct.2016.04.005.
[11]Pencina MJ,D′Agostino RBSr,D′Agostino RBJr,et al.Evaluating the added predictive ability of a new marker:from area under the ROC curve to reclassification and beyond[J].Stat Med,2008,27(2):157-172;discussion 207-112.doi:10.1002/sim.2929.
[12]Kramer AA,Zimmerman JE.Assessing the calibration of mortality benchmarks in critical care:The Hosmer-Lemeshow test revisited[J].Crit Care Med,2007,35(9):2052-2056.doi:10.1097/01.ccm.0000275267.64078.b0.
[13]Genders TS,Steyerberg EW,Hunink MG,et al.Prediction model to estimate presence of coronary artery disease:retrospective pooled analysis of existing cohorts[J].BMJ,2012,344:e3485.doi:10.1136/bmj.e3485.
[14]Cheng VY,Berman DS,Rozanski A,et al.Performance of the traditional age,sex,and angina typicality-based approach for estimating pretest probability of angiographically significant coronary artery disease in patients undergoing coronary computed tomographic angiography:results from the multinational coronary CT angiography evaluation for clinical outcomes:an international multicenter registry(CONFIRM)[J].Circulation,2011,124(22):2423-2432,1-8.doi:10.1161/CIRCULATIONAHA.111.039255.
[15]Zhou J,Liu Y,Huang L,et al.Validation and comparison of four models to calculate pretest probability of obstructive coronary artery disease in a Chinese population:A coronary computed tomographic angiography study[J].J Cardiovasc Comput Tomogr,2017,11(4):317-323.doi:10.1016/j.jcct.2017.05.004.
[16]Takamura K,Kondo T,Fujimoto S,et al.Incremental predictive value for obstructive coronary artery disease by combination of Duke Clinical Score and Agatston score[J].Eur Heart J Cardiovasc Imaging,2016,17(5):550-556.doi:10.1093/ehjci/jev233.
[17]Fujimoto S,Kondo T,Yamamoto H,et al.Development of new risk score for pre-test probability of obstructive coronary artery disease based on coronary CT angiography[J].Heart Vessels,2015,30(5):563-571.doi:10.1007/s00380-014-0515-6.
[18]Zhou J,Yang JJ,Yang X,et al.Impact of clinical guideline recommendations on the application of coronary computed tomographic angiography in patients with suspected stable coronary artery disease[J].Chin Med J(Engl),2016,129(2):135-141.doi:10.4103/0366-6999.173434.
[19]DeFilippis AP,Young R,Carrubba CJ,et al.An analysis of calibration and discrimination among multiple cardiovascular risk scores in a modern multiethnic cohort[J].Ann Intern Med,2015,162(4):266-275.doi:10.7326/m14-1281.
[20]McEvoy JW,Nasir K,DeFilippis AP,et al.Relationship of cigarette smoking with inflammation and subclinical vascular disease:the Multi-Ethnic Study of Atherosclerosis[J].Arterioscler Thromb Vasc Biol,2015,35(4):1002-1010.doi:10.1161/atvbaha.114.304960.
[21]Douglas PS,Hoffmann U,Patel MR,et al.Outcomes of anatomical versus functional testing for coronary artery disease[J].N Engl JMed,2015,372(14):1291-1300.doi:10.1056/NEJMoa1415516.(2018-08-28收稿2018-12-24修回)
[2]Task Force Members,Montalescot G,Sechtem U,et al.2013 ESCguidelines on the management of stable coronary artery disease:the Task Force on the management of stable coronary artery disease of the European Society of Cardiology[J].Eur Heart J,2013,34(38):2949-3003.doi:10.1093/eurheartj/eht296.
[3]Wolk MJ,Bailey SR,Doherty JU,et al.ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease:a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force,American Heart Association,American Society of Echocardiography,American Society of Nuclear Cardiology,Heart Failure Society of America,Heart Rhythm Society,Society for Cardiovascular Angiography and Interventions,Society of Cardiovascular Computed Tomography,Society for Cardiovascular Magnetic Resonance,and Society of Thoracic Surgeons[J].J Am Coll Cardiol,2014,63(4):380-406.doi:10.1016/j.jacc.2013.11.009.
[4]Pryor DB,Shaw L,McCANTS CB,et al.Value of the history and physical in identifying patients at increased risk for coronary artery disease[J].Ann Intern Med,1993,118(2):81-90.
[5]Genders TS,Steyerberg EW,Alkadhi H,et al.A clinical prediction rule for the diagnosis of coronary artery disease:validation,updating,and extension[J].Eur Heart J,2011,32(11):1316-1330.doi:10.1093/eurheartj/ehr014.
[6]Jensen JM,Voss M,Hansen VB,et al.Risk stratification of patients suspected of coronary artery disease:comparison of five different models[J].Atherosclerosis,2012,220(2):557-562.doi:10.1016/j.atherosclerosis.2011.11.027.
[7]Bittencourt MS,Hulten E,Polonsky TS,et al.European Society of Cardiology-Recommended Coronary Artery Disease Consortium Pretest Probability Scores More Accurately Predict Obstructive Coronary Disease and Cardiovascular Events Than the Diamond and Forrester Score:The Partners Registry[J].Circulation,2016,134(3):201-211.doi:10.1161/circulationaha.116.023396.
[8]Diamond GA.Right answer,wrong question:on the clinical relevance of the cardiovascular history[J].Circulation,2011,124(22):2377-2379.doi:10.1161/CIRCULATIONAHA.111.068718.
[9]Kumamaru KK,Arai T,Morita H,et al.Overestimation of pretest probability of coronary artery disease by Duke clinical score in patients undergoing coronary CT angiography in a Japanese population[J].J Cardiovasc Comput Tomogr,2014,8(3):198-204.doi:10.1016/j.jcct.2014.02.002.
[10]Cury RC,Abbara S,Achenbach S,et al.CAD-RADS(TM)Coronary Artery Disease-Reporting and Data System.An expert consensus document of the Society of Cardiovascular Computed Tomography(SCCT),the American College of Radiology(ACR)and the North American Society for Cardiovascular Imaging(NASCI).Endorsed by the American College of Cardiology[J].JCardiovasc Comput Tomogr,2016,10(4):269-281.doi:10.1016/j.jcct.2016.04.005.
[11]Pencina MJ,D′Agostino RBSr,D′Agostino RBJr,et al.Evaluating the added predictive ability of a new marker:from area under the ROC curve to reclassification and beyond[J].Stat Med,2008,27(2):157-172;discussion 207-112.doi:10.1002/sim.2929.
[12]Kramer AA,Zimmerman JE.Assessing the calibration of mortality benchmarks in critical care:The Hosmer-Lemeshow test revisited[J].Crit Care Med,2007,35(9):2052-2056.doi:10.1097/01.ccm.0000275267.64078.b0.
[13]Genders TS,Steyerberg EW,Hunink MG,et al.Prediction model to estimate presence of coronary artery disease:retrospective pooled analysis of existing cohorts[J].BMJ,2012,344:e3485.doi:10.1136/bmj.e3485.
[14]Cheng VY,Berman DS,Rozanski A,et al.Performance of the traditional age,sex,and angina typicality-based approach for estimating pretest probability of angiographically significant coronary artery disease in patients undergoing coronary computed tomographic angiography:results from the multinational coronary CT angiography evaluation for clinical outcomes:an international multicenter registry(CONFIRM)[J].Circulation,2011,124(22):2423-2432,1-8.doi:10.1161/CIRCULATIONAHA.111.039255.
[15]Zhou J,Liu Y,Huang L,et al.Validation and comparison of four models to calculate pretest probability of obstructive coronary artery disease in a Chinese population:A coronary computed tomographic angiography study[J].J Cardiovasc Comput Tomogr,2017,11(4):317-323.doi:10.1016/j.jcct.2017.05.004.
[16]Takamura K,Kondo T,Fujimoto S,et al.Incremental predictive value for obstructive coronary artery disease by combination of Duke Clinical Score and Agatston score[J].Eur Heart J Cardiovasc Imaging,2016,17(5):550-556.doi:10.1093/ehjci/jev233.
[17]Fujimoto S,Kondo T,Yamamoto H,et al.Development of new risk score for pre-test probability of obstructive coronary artery disease based on coronary CT angiography[J].Heart Vessels,2015,30(5):563-571.doi:10.1007/s00380-014-0515-6.
[18]Zhou J,Yang JJ,Yang X,et al.Impact of clinical guideline recommendations on the application of coronary computed tomographic angiography in patients with suspected stable coronary artery disease[J].Chin Med J(Engl),2016,129(2):135-141.doi:10.4103/0366-6999.173434.
[19]DeFilippis AP,Young R,Carrubba CJ,et al.An analysis of calibration and discrimination among multiple cardiovascular risk scores in a modern multiethnic cohort[J].Ann Intern Med,2015,162(4):266-275.doi:10.7326/m14-1281.
[20]McEvoy JW,Nasir K,DeFilippis AP,et al.Relationship of cigarette smoking with inflammation and subclinical vascular disease:the Multi-Ethnic Study of Atherosclerosis[J].Arterioscler Thromb Vasc Biol,2015,35(4):1002-1010.doi:10.1161/atvbaha.114.304960.
[21]Douglas PS,Hoffmann U,Patel MR,et al.Outcomes of anatomical versus functional testing for coronary artery disease[J].N Engl JMed,2015,372(14):1291-1300.doi:10.1056/NEJMoa1415516.(2018-08-28收稿2018-12-24修回)