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

Validation and comparison of pretest probability of coronary artery disease by using coronary CTA in Chinese patients with stale chest pain

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.