• Marcio Sommer Bittencourt, Edward Hulten, Tamar S Polonsky, Udo Hoffman, Khurram Nasir, Suhny Abbara, Marcelo Di Carli, and Ron Blankstein.
• From the Center for Clinical and Epidemiological Research, University Hospital and São Paulo State Cancer Institute, University of São Paulo School of Medicine, Sao Paulo, Brazil (M.S.B.); Cardiovascular Imaging Program, Departments of Medicine and Radiology; Brigham and Women's Hospital; Harvard Medical School, Boston, MA (M.S.B., E.H., M.D.C., R.B.); Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil (M.S.B.); Cardiology Service, Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD (E.H.); Department of Medicine, University of Chicago, Chicago, IL (T.S.P.); Cardiac MR PET CT Program, Department of Radiology, Division of Cardiac Imaging, Massachusetts General Hospital; Harvard Medical School, Boston (U.H., S.A.); Baptist Health South Florida, Miami, FL (K.N.); and Department of Radiology, University of Texas Southwestern, Dallas (S.A.).
• Circulation. 2016 Jul 19; 134 (3): 201-11.

BackgroundThe most appropriate score for evaluating the pretest probability of obstructive coronary artery disease (CAD) is unknown. We sought to compare the Diamond-Forrester (DF) score with the 2 CAD consortium scores recently recommended by the European Society of Cardiology.MethodsWe included 2274 consecutive patients (age, 56±13 years; 57% male) without prior CAD referred for coronary computed tomographic angiography. Computed tomographic angiography findings were used to determine the presence or absence of obstructive CAD (≥50% stenosis). We compared the DF score with the 2 CAD consortium scores with respect to their ability to predict obstructive CAD and the potential implications of these scores on the downstream use of testing for CAD, as recommended by current guidelines.ResultsThe DF score did not satisfactorily fit the data and resulted in a significant overestimation of the prevalence of obstructive CAD (P<0.001); the CAD consortium basic score had no significant lack of fitness; and the CAD consortium clinical provided adequate goodness of fit (P=0.39). The DF score had a lower discrimination for obstructive CAD, with an area under the receiver-operating characteristics curve of 0.713 versus 0.752 and 0.791 for the CAD consortium models (P<0.001 for both). Consequently, the use of the DF score was associated with fewer individuals being categorized as requiring no additional testing (8.3%) compared with the CAD consortium models (24.6% and 30.0%; P<0.001). The proportion of individuals with a high pretest probability was 18% with the DF and only 1.1% with the CAD consortium scores (P<0.001) CONCLUSIONS: Among contemporary patients referred for noninvasive testing, the DF risk score overestimates the risk of obstructive CAD. On the other hand, the CAD consortium scores offered improved goodness of fit and discrimination; thus, their use could decrease the need for noninvasive or invasive testing while increasing the yield of such tests.© 2016 American Heart Association, Inc.

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