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Determining the pretest probability of angiographically significant (50% stenosis) coronary artery disease (CAD) in symptomatic patients relies on the Diamond and Forrester (DF) classification, which was derived from a cohort referred for invasive coronary angiography. The accuracy of this approach in patients referred for noninvasive coronary angiography is not fully known. Consecutive patients without known CAD referred for coronary computed tomographic angiography (CCTA) were evaluated. Chest pain was prospectively categorized as nonanginal, atypical angina, typical angina, or asymptomatic. The pretest likelihood of angiographically significant CAD was estimated using DF classification and compared with observed rates of angiographically significant CAD on CCTA. Among 1,027 patients (41% women; mean age 50 - 12 years), 38 (4%) had nonanginal symptoms, 643 (63%) had atypical angina, 72 (7%) had typical angina, and 274 (26%) were asymptomatic. The prevalence of angiographically significant CAD in patients with nonanginal chest pain, atypical angina, typical angina, and no symptoms was 1 (3%), 55 (9%), 14 (19%), and 25 (9%), respectively (p <0.001). DF classification significantly overestimated angiographically significant CAD prevalence across all symptom classifications, genders, and ages despite adjustment for risk factors (p <0.001 for all comparisons). DF classification had an area under the receiver-operating characteristic curve of 0.72 (95% confidence interval 0.66 to 0.78), which was not significantly different from age alone (0.69) or age, symptoms, and risk factors (0.68). In conclusion, in a low- to intermediate-risk cohort referred for CCTA, DF classification significantly overestimated angiographically significant CAD prevalence across all age, gender, and symptom strata. The DF classification may overestimate the pretest probability of angiographically significant CAD in contemporary patients referred for CCTA. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to describe the prevalence and severity of coronary artery disease (CAD) in relation to prognosis in symptomatic patients without coronary artery calcification (CAC) undergoing coronary computed tomography angiography (CCTA). Background: The frequency and clinical relevance of CAD in patients without CAC are unclear. Methods: We identified 10,037 symptomatic patients without CAD who underwent concomitant CCTA and CAC scoring. CAD was assessed as <50%, ≥50%, and ≥70% stenosis. All-cause mortality and the composite endpoint of mortality, myocardial infarction, or late coronary revascularization (≥90 days after CCTA) were assessed. Results: Mean age was 57 years, 56% were men, and 51% had a CAC score of 0. Among patients with a CAC score of 0, 84% had no CAD, 13% had nonobstructive stenosis, and 3.5% had ≥50% stenosis (1.4% had ≥70% stenosis) on CCTA. A CAC score >0 had a sensitivity, specificity, and negative and positive predictive values for stenosis ≥50% of 89%, 59%, 96%, and 29%, respectively. During a median of 2.1 years, there was no difference in mortality among patients with a CAC score of 0 irrespective of obstructive CAD. Among 8,907 patients with follow-up for the composite endpoint, 3.9% with a CAC score of 0 and ≥50% stenosis experienced an event (hazard ratio: 5.7; 95% confidence interval: 2.5 to 13.1; p < 0.001) compared with 0.8% of patients with a CAC score of 0 and no obstructive CAD. Receiver-operator characteristic curve analysis demonstrated that the CAC score did not add incremental prognostic information compared with CAD extent on CCTA for the composite endpoint (CCTA area under the curve = 0.825; CAC + CCTA area under the curve = 0.826; p = 0.84). Conclusions: In symptomatic patients with a CAC score of 0, obstructive CAD is possible and is associated with increased cardiovascular events. CAC scoring did not add incremental prognostic information to CCTA. [Copyright &y& Elsevier]