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Original research
Physician judgement in predicting obstructive coronary artery disease and adverse events in chest pain patients
  1. Christopher B Fordyce1,
  2. C Larry Hill2,
  3. Daniel B Mark2,
  4. Brooke Alhanti2,
  5. Patricia A Pellikka3,
  6. Udo Hoffmann4,
  7. Manesh R Patel2,
  8. Pamela S Douglas2
  9. on behalf of the PROMISE Investigators
  1. 1 Division of Cardiology and Centre for Cardiovascular Innovation, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
  2. 2 Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
  3. 3 Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
  4. 4 Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Dr Christopher B Fordyce, Division of Cardiology, University of British Columbia, Vancouver, BC V5Z 1M9, Canada; cfordyce{at}


Objective To evaluate informal physician judgement versus pretest probability scores in estimating risk in patients with suspected coronary artery disease (CAD).

Methods We included 4533 patients from the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial. Physicians categorised a priori the pretest probability of obstructive CAD (≥70% or ≥50% left main); Diamond-Forrester (D-F) and European Society of Cardiology (ESC) pretest probability estimates were calculated. Agreement was calculated using the κ statistic; logistic regression evaluated estimates of pretest CAD probability and actual CAD (as determined by CT coronary angiography), and clinical outcomes were modelled using Cox proportional hazard models.

Results Physician estimates agreed poorly with D-F (κ 0.16; 95% CI 0.14 to 0.18) and ESC (κ 0.04; 95% CI 0.02 to 0.05). Actual obstructive CAD was significantly more prevalent in both the high-likelihood (OR 3.30; 95% CI 2.30 to 4.74) and the intermediate-likelihood (OR 1.43; 95% CI 1.16 to 1.76) physician-estimated groups versus the low-likelihood group; ESC similarly differentiated between the three groups (OR 9.07; 95% CI 2.87 to 28.70; and OR 3.87; 95% CI 1.22 to 12.28). However, using D-F, only the high-probability group differed (OR 2.49; 95% CI 1.74 to 3.54). Only physician estimates were associated with a higher incidence of adjusted death/myocardial infarction/unstable angina hospitalisation in the high-probability versus low-probability group (HR 2.68; 95% CI 1.52 to 4.74); neither pretest probability score provided prognostic information.

Conclusions Compared with D-F and ESC estimates, physician judgement more accurately identified obstructive CAD and worse patient outcomes. Integrating physician judgement may improve risk prediction for patients with stable chest pain.

Trial registration number NCT01174550.

  • chest pain
  • diagnostic imaging
  • outcome assessment
  • healthcare

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Twitter @pattypellikka, @pamelasdouglas

  • Contributors CBF acts as guarantor and takes responsibility for the overall content of the manuscript. PD was involved in the design of the analysis and provided critical review. CLH and BA provided statistical analysis and support. DM, PAP, UH and MRP critically reviewed the manuscript.

  • Funding The PROMISE trial was funded by the National Heart, Lung, and Blood Institute grants R01 HL098237, R01 HL098236, R01 HL098305 and R01 HL098235.

  • Disclaimer The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The views expressed in this article do not necessarily represent the official views of the National Heart, Lung, and Blood Institute.

  • Competing interests CBF: Consulting fees/honoraria from Bayer, Novo Nordisk, Sanofi, Boehringer Ingelheim, Pfizer; research support from Bayer; Steering Committee service for HeartFlow. DM: Consultant fees/honoraria from Medtronic; research support from AGA Medical, AstraZeneca, Bayer Healthcare Pharmaceuticals, BMS, Eli Lilly, Gilead, Merck & Co., Inc. UH: Research support from HeartFlow. MRP: Consultant fees/honoraria from Bayer Healthcare, Genzyme, Medscape -, Merck; research support from AHRQ, AstraZeneca, Jansen, Johnson & Johnson, Maquet, National Heart Lung and Blood Institute, PCORI. PD: Research support from HeartFlow. No other disclosures were reported.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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