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Value of the History and Physical in Identifying Patients at Increased Risk for Coronary Artery Disease

David B. Pryor, MD; Linda Shaw, AB; Charles B. McCants, BS; Kerry L. Lee, PhD; Daniel B. Mark, MD, MPH; Frank E. Harrell, PhD; Lawrence H. Muhlbaier, PhD; and Robert M. Califf, MD
[+] Article and Author Information

From Duke University Medical Center, Durham, North Carolina. Requests for Reprints: David B. Pryor, MD, Duke University Medical Center, Box 3531, Durham, NC 27710. Grant Support: In part by research grants HS-04873, HS-06503, and HS-05635 from the Agency for Health Care Policy and Research; research grant HL-17670 from the National Heart, Lung and Blood Institute; and research grant LM04613 from the National Library of Medicine.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1993;118(2):81-90. doi:10.7326/0003-4819-118-2-199301150-00001
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Objective: To determine whether information from the physician's initial evaluation of patients with suspected coronary artery disease predicts coronary anatomy at catheterization and 3-year survival.

Design: Prospective validation of regression model estimates in an outpatient cohort.

Setting: University medical center.

Patients: A total of 1030 consecutive outpatients referred for noninvasive testing for suspected coronary artery disease; 168 of these patients subsequently underwent catheterization within 90 days.

Measurements: Information from the initial history, physical examination, electrocardiogram, and chest radiograph was used to predict coronary anatomy (the likelihood of any significant coronary disease, severe disease [left main or three-vessel], and significant left main disease) among 168 catheterized patients and to estimate 3-year survival among all patients. These estimates were compared with those based on treadmill testing. Cardiovascular testing charges were calculated for all patients.

Results: Predicted coronary anatomy and survival closely corresponded to actual findings. Compared with the treadmill exercise test, initial evaluation was slightly better able to distinguish patients with or without any coronary disease and was similar in the ability to identify patients at increased risk for dying or with anatomically severe disease. Based on arbitrary definitions, 37% to 66% of patients were at low risk and responsible for 31% to 56% of the charges for cardiovascular testing.

Conclusions: The physician's initial evaluation, despite the subjective nature of much of the information gathered, can be used to identify patients likely to benefit from further testing. The development of strategies for cost-conscious quality care must begin with the history, physical examination, and simple laboratory testing.

Figures

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Figure 1.
Reliability of the models for estimating the likelihood of significant coronary artery disease, with distributions of predicted probability.Left panel.Right panel.

Significant disease was defined as 75% or greater narrowing of a major coronary artery. The observed proportion with significant disease is shown as a function of the mean predicted likelihood of significant coronary artery disease for deciles of predicted risk. The solid line represents “perfect” reliability and is shown for reference. The distribution of predicted likelihood of significant disease is shown for patients with and without significant disease.

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Figure 2.
Reliability of the models for estimating the likelihood of severe coronary artery disease, with distributions of predicted probability.Left panel.Right panel.

Severe disease was defined as left main or three-vessel disease. The observed proportion with severe disease is shown as a function of the mean predicted likelihood of severe coronary artery disease for quintiles of predicted risk. The solid line represents “perfect” reliability and is shown for reference. The distribution of predicted likelihood of severe disease is shown for patients with and without severe disease.

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Figure 3.
Reliability of the models for estimating the likelihood of left main coronary artery disease, with distributions of predicted probability.Left panel.Right panel.

The observed proportion with left main disease is shown as a function of the mean predicted likelihood of left main coronary artery disease for quintiles of predicted risk. The solid line represents “perfect” reliability and is shown for reference. The distribution of predicted likelihood of left main disease is shown for patients with and without left main disease.

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Figure 4.
Reliability of the models for estimating the likelihood of 3-year survival, with distributions of predicted probability.Left panel.Right panel.

The observed proportion who survive 3 years is shown as a function of the mean predicted likelihood of 3-year survival for deciles of predicted risk. The solid line represents “perfect” reliability and is shown for reference. The distribution of predicted 3-year survival is shown for patients who did and did not die within three years of cardiovascular causes.

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Figure 5.
Survival in high- and low-risk patients.

Using estimated 3-year survival rates, the sample was divided into two equal-sized groups of patients at “high” and “low” risk. Kaplan-Meier survival curves are shown.

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Figure 6.
Receiver-operating characteristic curves comparing the discriminatory ability of the initial assessment with that of the exercise treadmill test.(panel A)(panel B)(panel C)(panel D)

Results for any significant disease ; severe disease (left main or three-vessel) ; left main disease ; and survival are shown.

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