Clinical pre-test probability for obstructive coronary artery disease: insights from the European DISCHARGE pilot study

Sarah Feger, Paolo Ibes, Adriane E. Napp, Alexander Lembcke, Michael Laule, Henryk Dreger, Björn Bokelmann, Gershan K. Davis, Giles Roditi, Ignacio Diez, Stephen Schröder, Fabian Plank, Pal Maurovich-Horvat, Radosav Vidakovic, Josef Veselka, Malgorzata Ilnicka-Suckiel, Andrejs Erglis, Teodora Benedek, José Rodriguez-Palomares, Luca SabaKlaus F. Kofoed, Matthias Gutberlet, Filip Ađić, Mikko Pietilä, Rita Faria, Audrone Vaitiekiene, Jonathan D. Dodd, Patrick Donnelly, Marco Francone, Cezary Kepka, Balazs Ruzsics, Jacqueline Müller-Nordhorn, Peter Schlattmann, Marc Dewey*

*Corresponding author for this work

Research output: Contribution to journalArticle (journal)peer-review

13 Citations (Scopus)


Objectives: To test the accuracy of clinical pre-test probability (PTP) for prediction of obstructive coronary artery disease (CAD) in a pan-European setting. Methods: Patients with suspected CAD and stable chest pain who were clinically referred for invasive coronary angiography (ICA) or computed tomography (CT) were included by clinical sites participating in the pilot study of the European multi-centre DISCHARGE trial. PTP of CAD was determined using the Diamond-Forrester (D+F) prediction model initially introduced in 1979 and the updated D+F model from 2011. Obstructive coronary artery disease (CAD) was defined by one at least 50% diameter coronary stenosis by both CT and ICA. Results: In total, 1440 patients (654 female, 786 male) were included at 25 clinical sites from May 2014 until July 2017. Of these patients, 725 underwent CT, while 715 underwent ICA. Both prediction models overestimated the prevalence of obstructive CAD (31.7%, 456 of 1440 patients, PTP: initial D+F 58.9% (28.1–90.6%), updated D+F 47.3% (34.2–59.9%), both p < 0.001), but overestimation of disease prevalence was higher for the initial D+F (p < 0.001). The discriminative ability was higher for the updated D+F 2011 (AUC of 0.73 95% confidence interval [CI] 0.70–0.76 versus AUC of 0.70 CI 0.67–0.73 for the initial D+F; p < 0.001; odds ratio (or) 1.55 CI 1.29–1.86, net reclassification index 0.11 CI 0.05–0.16, p < 0.001). Conclusions: Clinical PTP calculation using the initial and updated D+F prediction models relevantly overestimates the actual prevalence of obstructive CAD in patients with stable chest pain clinically referred for ICA and CT suggesting that further refinements to improve clinical decision-making are needed. Trial registration: Key Points: • Clinical pre-test probability calculation using the initial and updated D+F model overestimates the prevalence of obstructive CAD identified by ICA and CT. • Overestimation of disease prevalence is higher for the initial D+F compared with the updated D+F. • Diagnostic accuracy of PTP assessment varies strongly between different clinical sites throughout Europe.

Original languageEnglish
Pages (from-to)1471-1481
Number of pages11
JournalEuropean Radiology
Issue number3
Publication statusPublished - 9 Sept 2020


  • Computed tomography angiography
  • Coronary artery disease
  • Prevalence
  • Probability of disease


Dive into the research topics of 'Clinical pre-test probability for obstructive coronary artery disease: insights from the European DISCHARGE pilot study'. Together they form a unique fingerprint.

Cite this