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Artificial neural network-based model enhances risk stratification and reduces non-invasive cardiac stress imaging compared to Diamond–Forrester and Morise risk assessment models: A prospective study

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Coronary artery disease (CAD) accounts for more than half of all cardiovascular events. Stress testing remains the cornerstone for non-invasive assessment of patients with possible or known CAD. Clinical utilization reviews show that most patients presenting for evaluation of stable CAD by stress testing are categorized as low risk prior to the test. Attempts to enhance risk stratification of individuals who are sent for stress testing seem to be more in need today. The present study compares artificial neural networks (ANN)-based prediction models to the other risk models being used in practice (the Diamond–Forrester and the Morise models).


In our study, we prospectively recruited patients who were 19 years of age or older, and were being evaluated for coronary artery disease with imaging-based stress tests. For ANN, the network architecture employed a systematic method, where the number of neurons is changed incrementally, and bootstrapping was performed to evaluate the accuracy of the models.


We prospectively enrolled 486 patients. The mean age of patients undergoing stress test was 55.2 ± 11.2 years, 35% were women, and 12% had a positive stress test for ischemic heart disease. When compared to Diamond–Forrester and Morise risk models, the ANN model for predicting ischemia provided higher discriminatory power (DP)(1.61), had a negative predictive value of 98%, Sensitivity 91% [81%-97%], Specificity 65% [60%-79%], positive predictive value 26%, and a potential 59% reduction of non-invasive imaging.


The ANN models improved risk stratification when compared to the other risk scores (Diamond–Forrester and Morise) with a 98% negative predictive value and a significant potential reduction in non-invasive imaging tests.

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Correspondence to Hussain A. Isma’eel MD.

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Hussain A. Isma’eel and George E. Sakr—co-authors with equal contribution.

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Appendix: Discretization of Morise and DF scores from pretest probabilities to positive/negative outcomes

Appendix: Discretization of Morise and DF scores from pretest probabilities to positive/negative outcomes

Table 4 allows us to compute Morise score.14,15 The Morise score represents a pretest probability of stenosis. We picked a cutoff point for the total score and assumed that if the total score is higher than this cutoff then the result is positive, otherwise, it is negative. This cutoff point was varied over all possible values, which yielded the ROC curve below. Similar to our group’s previous work,30 the cutoff point that yielded the highest DP was then used (Table 5).

Table 4 Morise score calculation: how to calculate the pretest score and assigned risk groups
Table 5 Method of transforming Diamond–Forrester risk score into a numerical probability

The same was applied to DF.14

$$ \begin{aligned} & {\text{Score}} = 0.04\,*\,{\text{age}} + 1.34\,*\,{\text{Male}} + 1.91\,*\,{\text{Typical}} + 0.64\,*\,{\text{Atypical}} - 4.37 \\ & {\text{Probability}} = \exp ({\text{score}})/(1 + \exp ({\text{score}})) \\ \end{aligned} $$

A cutoff probability was chosen and we assumed that if the current probability is higher than the cutoff then the result is positive otherwise it is negative. This cutoff varied between 0 and 1 with a step of 0.01 which led to the ROC below (Figures 6, 7). The area under the curve for Morise score is 0.59 and the area under the curve for DF is 0.55 compared to 0.7 by ANN (P < .01).

Figure 6
figure 6

AUROC for Morise

Figure 7
figure 7


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Isma’eel, H.A., Sakr, G.E., Serhan, M. et al. Artificial neural network-based model enhances risk stratification and reduces non-invasive cardiac stress imaging compared to Diamond–Forrester and Morise risk assessment models: A prospective study. J. Nucl. Cardiol. 25, 1601–1609 (2018).

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