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European Radiology

, Volume 28, Issue 9, pp 4006–4017 | Cite as

Applicability and accuracy of pretest probability calculations implemented in the NICE clinical guideline for decision making about imaging in patients with chest pain of recent onset

  • Robert Roehle
  • Viktoria Wieske
  • Georg M. Schuetz
  • Pascal Gueret
  • Daniele Andreini
  • Willem Bob Meijboom
  • Gianluca Pontone
  • Mario Garcia
  • Hatem Alkadhi
  • Lily Honoris
  • Jörg Hausleiter
  • Nuno Bettencourt
  • Elke Zimmermann
  • Sebastian Leschka
  • Bernhard Gerber
  • Carlos Rochitte
  • U. Joseph Schoepf
  • Abbas Arjmand Shabestari
  • Bjarne Nørgaard
  • Akira Sato
  • Juhani Knuuti
  • Matthijs F. L. Meijs
  • Harald Brodoefel
  • Shona M. M. Jenkins
  • Kristian Altern Øvrehus
  • Axel Cosmus Pyndt Diederichsen
  • Ashraf Hamdan
  • Bjørn Arild Halvorsen
  • Vladimir Mendoza Rodriguez
  • Yung Liang Wan
  • Johannes Rixe
  • Mehraj Sheikh
  • Christoph Langer
  • Said Ghostine
  • Eugenio Martuscelli
  • Hiroyuki Niinuma
  • Arthur Scholte
  • Konstantin Nikolaou
  • Geir Ulimoen
  • Zhaoqi Zhang
  • Hans Mickley
  • Koen Nieman
  • Philipp A. Kaufmann
  • Ronny Ralf Buechel
  • Bernhard A. Herzog
  • Melvin Clouse
  • David A. Halon
  • Jonathan Leipsic
  • David Bush
  • Reda Jakamy
  • Kai Sun
  • Lin Yang
  • Thorsten Johnson
  • Jean-Pierre Laissy
  • Roy Marcus
  • Simone Muraglia
  • Jean-Claude Tardif
  • Benjamin Chow
  • Narinder Paul
  • David Maintz
  • John Hoe
  • Albert de Roos
  • Robert Haase
  • Michael Laule
  • Peter Schlattmann
  • Marc Dewey
Cardiac

Abstract

Objectives

To analyse the implementation, applicability and accuracy of the pretest probability calculation provided by NICE clinical guideline 95 for decision making about imaging in patients with chest pain of recent onset.

Methods

The definitions for pretest probability calculation in the original Duke clinical score and the NICE guideline were compared. We also calculated the agreement and disagreement in pretest probability and the resulting imaging and management groups based on individual patient data from the Collaborative Meta-Analysis of Cardiac CT (CoMe-CCT).

Results

4,673 individual patient data from the CoMe-CCT Consortium were analysed. Major differences in definitions in the Duke clinical score and NICE guideline were found for the predictors age and number of risk factors. Pretest probability calculation using guideline criteria was only possible for 30.8 % (1,439/4,673) of patients despite availability of all required data due to ambiguity in guideline definitions for risk factors and age groups. Agreement regarding patient management groups was found in only 70 % (366/523) of patients in whom pretest probability calculation was possible according to both models.

Conclusions

Our results suggest that pretest probability calculation for clinical decision making about cardiac imaging as implemented in the NICE clinical guideline for patients has relevant limitations.

Key Points

• Duke clinical score is not implemented correctly in NICE guideline 95.

• Pretest probability assessment in NICE guideline 95 is impossible for most patients.

• Improved clinical decision making requires accurate pretest probability calculation.

• These refinements are essential for appropriate use of cardiac CT.

Keywords

Coronary artery disease Multidetector computed tomography NICE clinical guideline Duke clinical score Pretest probability 

Abbreviations

CACS

Coronary artery calcium score

CAD

Coronary artery disease

CoMe-CCT

Collaborative Meta-Analysis of Cardiac CT

CT

Computed tomography

CTA

Computed tomography angiography

ECG

Exercise electrocardiogram

ICA

Invasive coronary angiography

NICE

National Institute for Health and Care Excellence

PMG

Patient management group

Notes

Funding

The authors of this manuscript state that the CoMe-CCT project received funding from the joint program of the German Research Foundation (DFG) and the German Federal Ministry of Education and Research (BMBF) for meta-analyses.

Compliance with ethical standards

Guarantor

The scientific guarantor of this publication is Marc Dewey.

Conflict of interest

All authors have completed the Unified Competing Interest form at www.icmje.org/disclosure.pdf (available on request from the corresponding author) and declare: RR, VW, PG, WBM, MG, HA, LH, NB, EZ, SL, BG, CR, AAS, BN, AS, MFLM, HB, SMMJ, KAØ, ACPD, AH, BAH, VMR, YLW, JR, MS, CL, SG, EM, HN, AS, KN, GU, ZZ, HM, MC, DAH, DB, RJ, KS, LY, TJ, JPL, RM, SM, JCT, DM, AdR and ML have nothing to disclose. GMS reports grants from German Federal Ministry of Education and Research (BMBF), during the conduct of the study. DA reports other from GE Healthcare, during the conduct of the study; other from GE Healthcare, outside the submitted work. GP reports other from General Electric, other from Bayer, other from Medtronic, other from Heartflow, outside the submitted work. JH reports grants from Siemens Medical Solutions, outside the submitted work. UJS reports grants from Bayer, grants from Bracco, grants from GE, grants from Medrad, grants from Siemens Healthcare, outside the submitted work. JK reports personal fees from Lantheus Inc, grants from Orion Pharma, outside the submitted work. KN reports non-financial support from Siemens Medical Solutions, grants from GE Healthcare, other from Toshiba Medical Systems, non-financial support from Abbott Vascular, grants from Bayer healthcare, outside the submitted work. PK, RRB, and BH report that the University Hospital Zurich holds a research contract with GE Healthcare. JL reports personal fees from GE Healthcare, personal fees from Heartflow, outside the submitted work. BC reports research grants from GE healthcare and educational support from TeraRecon, outside the submitted work. NP reports grants from Toshiba Medical System, outside the submitted work. JH reports grants and personal fees from Toshiba Medical Systems, during the conduct of the study. RH reports grants from Toshiba, outside the submitted work. PS reports grants from Ministry of Education and Research (BMBF) for meta-analyses as part of the joint programme "clinical trials" of the BMBF and the German Science Foundation (DFG), during the conduct of the study; grants from German Science Foundation (DFG), grants from European Union, outside the submitted work. MD has received grant support from the Heisenberg Program of the DFG for a professorship (DE 1361/14-1), the FP7 Program of the European Commission for the randomized multicentre DISCHARGE trial (603266-2, HEALTH-2012.2.4.-2), the European Regional Development Fund (20072013 2/05, 20072013 2/48), the German Heart Foundation/German Foundation of Heart Research (F/23/08, F/27/10), the Joint Program from the German Research Foundation (DFG) and the German Federal Ministry of Education and Research (BMBF) for meta-analyses (01KG1013, 01KG1110, 01KG1110), GE Healthcare, Bracco, Guerbet, and Toshiba Medical Systems. MD has also received lecture fees from Toshiba Medical Systems, Guerbet, Cardiac MR Academy Berlin, and Bayer (Schering-Berlex). MD is a consultant to Guerbet and one of the principal investigators of multicentre studies (CORE-64 and 320) on coronary CT angiography sponsored by Toshiba Medical Systems. He is also the editor of Coronary CT Angiography and Cardiac CT, both published by Springer, and offers hands-on workshops on cardiovascular imaging (www.ct-kurs.de). MD is an associate editor of Radiology and European Radiology. Institutional master research agreements exist with Siemens Medical Solutions, Philips Medical Systems, and Toshiba Medical Systems. The terms of these arrangements are managed by the legal department of Charité – Universitätsmedizin Berlin.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was not required for this study because of the retrospective study design (meta-analysis).

Ethical approval

Institutional Review Board approval was not required because of the retrospective study design (meta-analysis).

Methodology

• diagnostic study

• individual patient data meta-analysis

• multicentre study

Supplementary material

330_2018_5322_MOESM1_ESM.docx (21 kb)
ESM 1 (DOCX 20 kb)
330_2018_5322_MOESM2_ESM.xls (29 kb)
ESM 2 (XLS 29 kb)

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Copyright information

© European Society of Radiology 2018
corrected publication May 2018

Authors and Affiliations

  • Robert Roehle
    • 1
  • Viktoria Wieske
    • 1
  • Georg M. Schuetz
    • 1
  • Pascal Gueret
    • 2
  • Daniele Andreini
    • 3
    • 4
  • Willem Bob Meijboom
    • 5
  • Gianluca Pontone
    • 3
  • Mario Garcia
    • 6
  • Hatem Alkadhi
    • 7
  • Lily Honoris
    • 8
  • Jörg Hausleiter
    • 9
  • Nuno Bettencourt
    • 10
  • Elke Zimmermann
    • 1
  • Sebastian Leschka
    • 11
  • Bernhard Gerber
    • 12
  • Carlos Rochitte
    • 13
  • U. Joseph Schoepf
    • 14
  • Abbas Arjmand Shabestari
    • 15
  • Bjarne Nørgaard
    • 16
  • Akira Sato
    • 17
  • Juhani Knuuti
    • 18
  • Matthijs F. L. Meijs
    • 19
  • Harald Brodoefel
    • 20
  • Shona M. M. Jenkins
    • 21
  • Kristian Altern Øvrehus
    • 22
    • 23
  • Axel Cosmus Pyndt Diederichsen
    • 22
  • Ashraf Hamdan
    • 24
    • 25
  • Bjørn Arild Halvorsen
    • 26
  • Vladimir Mendoza Rodriguez
    • 27
  • Yung Liang Wan
    • 28
    • 29
  • Johannes Rixe
    • 30
  • Mehraj Sheikh
    • 31
    • 32
  • Christoph Langer
    • 33
    • 34
  • Said Ghostine
    • 35
  • Eugenio Martuscelli
    • 36
  • Hiroyuki Niinuma
    • 37
  • Arthur Scholte
    • 38
  • Konstantin Nikolaou
    • 39
  • Geir Ulimoen
    • 40
  • Zhaoqi Zhang
    • 41
  • Hans Mickley
    • 22
  • Koen Nieman
    • 42
    • 43
  • Philipp A. Kaufmann
    • 44
  • Ronny Ralf Buechel
    • 44
  • Bernhard A. Herzog
    • 44
  • Melvin Clouse
    • 45
  • David A. Halon
    • 46
    • 47
  • Jonathan Leipsic
    • 48
  • David Bush
    • 49
    • 50
  • Reda Jakamy
    • 51
  • Kai Sun
    • 52
  • Lin Yang
    • 41
  • Thorsten Johnson
    • 53
  • Jean-Pierre Laissy
    • 54
  • Roy Marcus
    • 55
  • Simone Muraglia
    • 56
  • Jean-Claude Tardif
    • 57
  • Benjamin Chow
    • 58
  • Narinder Paul
    • 59
    • 60
  • David Maintz
    • 61
  • John Hoe
    • 62
  • Albert de Roos
    • 63
  • Robert Haase
    • 1
  • Michael Laule
    • 64
  • Peter Schlattmann
    • 65
  • Marc Dewey
    • 1
  1. 1.Department of Radiology, Charité – Universitätsmedizin Berlin Campus MitteHumboldt-Universität zu Berlin, Freie Universität BerlinBerlinGermany
  2. 2.Cardiology DepartmentHenri Mondor Hospital, University Paris Est CreteilCréteilFrance
  3. 3.Centro Cardiologico Monzino, IRCCSMilanItaly
  4. 4.Department of Clinical Sciences and Community Health, Cardiovascular SectionUniversity of MilanMilanItaly
  5. 5.IJsselland ZiekenhuisCapelle a/d IJsselThe Netherlands
  6. 6.Montefiore, the University Hospital for the Albert Einstein College of MedicineNew York CityUSA
  7. 7.Institute of Diagnostic and Interventional RadiologyUniversity Hospital ZurichZurichSwitzerland
  8. 8.Aurora Health CareMilwaukeeUSA
  9. 9.Medizinische Klinik und Poliklinik I, Ludwig-Maximilians-University of MunichMunichGermany
  10. 10.Department of CardiologyCentro Hospitalar de Vila Nova de Gaia/EspinhoGaiaPortugal
  11. 11.Department of Radiology and Nuclear Medicine Kantonsspital St. GallenSt. GallenSwitzerland
  12. 12.Division of Cardiology, Cardiovascular Center, Cliniques Universitaires St. LucInstitut de Recherche Clinique et ExperimentaleBrusselsBelgium
  13. 13.Heart Institute - InCor - University of São Paulo Medical SchoolSão PauloBrazil
  14. 14.Department of Radiology and Radiological ScienceMedical University of South CarolinaCharlestonUSA
  15. 15.Department of RadiologyModarres Hospital, Shahid Beheshti University of Medical SciencesTehranIran
  16. 16.Department Cardiology BAarhus University Hospital SkejbyAarhusDenmark
  17. 17.Cardiovascular Division, Faculty of MedicineUniversity of TsukubaTsukubaJapan
  18. 18.Turku University Hospital and University of TurkuTurkuFinland
  19. 19.Department of CardiologyUniversity Medical Center UtrechtUtrechtThe Netherlands
  20. 20.Department of RadiologyUniversity of RegensburgRegensburgGermany
  21. 21.Glasgow Royal Infirmary and Stobhill HospitalGlasgowUK
  22. 22.Department of CardiologyOdense University HospitalOdenseDenmark
  23. 23.Department of Cardiology Lillebælt Hospital –VejleVejleDenmark
  24. 24.Department of Internal Medicine/CardiologyDeutsches Herzzentrum BerlinBerlinGermany
  25. 25.Heart Institute, Chaim Sheba Medical CenterTel HashomerIsrael
  26. 26.Medical Department, Ostfold Hospital TrustFredrikstadNorway
  27. 27.National Institute of Cardiology and Cardiovascular, SurgeryHavanaCuba
  28. 28.Department of Medical Imaging and Radiological Sciences, College of MedicineChang Gung UniversityTaoyuanTaiwan
  29. 29.Department of Medical Imaging and InterventionChang Gung Memorial Hospital at LinkouTaoyuanTaiwan
  30. 30.Medizinische Klinik I (Kardiologie, Angiologie)Universitätsklinikum Giessen und Marburg GmbHGiessenGermany
  31. 31.Department of Radiology, Faculty of MedicineKuwait UniversityKuwait CityKuwait
  32. 32.Mubarak Al Kabeer HospitalJabriyaKuwait
  33. 33.Klinik für Innere Medizin III mit Schwerpunkt Kardiologie und Angiologie, UKSHKielGermany
  34. 34.Kardiologische Klinik, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität BochumBad OeynhausenGermany
  35. 35.Cardiologie diagnostique et interventionnelle, Centre Chirurgical Marie LannelongueLe Plessis RobinsonFrance
  36. 36.Department of Internal MedicineUniversity of Rome Tor VergataRomeItaly
  37. 37.Department of Medicine, St. Luke’s International HospitalTokyoJapan
  38. 38.Department of Cardiology, Leiden University Medical CenterLeidenThe Netherlands
  39. 39.Department of Diagnostic and Interventional RadiologyEberhard Karls Universität TübingenTübingenGermany
  40. 40.Aleris HospitalOsloNorway
  41. 41.Department of RadiologyBeijing Anzhen Hospital, Capital Medical UniversityBeijingChina
  42. 42.Department of CardiologyErasmus Medical CenterRotterdamThe Netherlands
  43. 43.Department of RadiologyErasmus Medical CenterRotterdamThe Netherlands
  44. 44.Department of Nuclear Medicine, Cardiac ImagingUniversity Hospital ZurichZurichSwitzerland
  45. 45.Department of Radiology, Beth Israel DeaconessHarvard UniversityBostonUSA
  46. 46.Department of Cardiovascular MedicineLady Davis Carmel Medical CenterHaifaIsrael
  47. 47.Ruth and Bruce Rappaport Faculty of MedicineTechnion, Israel Institute of TechnologyHaifaIsrael
  48. 48.Department of Radiology and Division of Cardiology UBCSt Paul’s HospitalVancouverCanada
  49. 49.Department of CardiologyJohns Hopkins UniversityBaltimoreUSA
  50. 50.Department of CardiologyJohns Hopkins Bayview Medical CenterBaltimoreUSA
  51. 51.Department of Interventional CardiologyUniversity Hospital CochinParisFrance
  52. 52.Department of RadiologyBaotou Central HospitalBaotou ShiChina
  53. 53.Department of Clinical RadiologyHospital Grosshadern of the University of MunichMunichGermany
  54. 54.Department of Diagnostic Imaging and Interventional RadiologyBichat University HospitalParisFrance
  55. 55.Department of Clinical Radiology, MunichLudwig-Maximilians-University of MunichMunichGermany
  56. 56.Cardiology Department, S. Chiara HospitalTrentoItaly
  57. 57.Research Center Montreal Heart Institute, Université de MontréalMontréalCanada
  58. 58.University of Ottawa, Heart InstituteOttawaCanada
  59. 59.Joint Department of Medical Imaging, University Health Network, Mount Sinai and Women’s College HospitalsTorontoCanada
  60. 60.University of TorontoTorontoCanada
  61. 61.Institute and Polyclinic for Diagnostic RadiologyUniversity of CologneCologneGermany
  62. 62.Department of Diagnostic RadiologyMt Elizabeth HospitalSingaporeSingapore
  63. 63.Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
  64. 64.Department of CardiologyCharité – Universitätsmedizin Berlin Campus Mitte, Humboldt-Universität zu Berlin, Freie Universität BerlinBerlinGermany
  65. 65.Department of Medical Statistics, Informatics and DocumentationUniversity Hospital of Friedrich Schiller University JenaJenaGermany

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