External Validation and Comparison of Two Clinical Prediction Models (PTP2013 and PTP2019) for Chest Pain in a Colombian Cohort

Aims The European Society of Cardiology (ESC) has proposed four pre-test probability (PTP) models for obstructive coronary artery disease (CAD). However, no studies have evaluated the diagnostic performance of any predictive model in the Latin American population. The aim of this study is to compare the PTP2013 and PTP2019 predictive models in order to determine which demonstrates a superior diagnostic performance for CAD in a cohort of Colombian patients.

A total of 408 patients who presented with chest pain and underwent coronary angiography (CA) and/or coronary computed tomography angiography (CCTA) at Fundación Santa Fe de Bogotá, between January 2019 and December 2023 were enrolled. Medical records were retrieved from the Hemodynamics and Radiology units. Pre-test probabilities were calculated for each patient using both the PTP2013 and PTP2019 models. CAD was defined as >50% stenosis on CA or CCTA. Each predictive model was assessed against CA and/or CCTA findings. The comparative performance of both models was evaluated.

Prevalence of obstructive CAD of 24.9%. The PR2019 model underestimated the probability of CAD by 59%, whereas the PTP2013 model overestimated it by 35.6%. PTP2019 model yielded a C-statistic of 0.610 [95% CI: 0.544 - 0.676], while the PTP2013 model reported a C-statistic of 0.633 [95% CI: 0.570 - 0.696] (comparative p-value: 0.060). The net reclassification improvement was 14.7%). At a 15% threshold, the PTP2013 model demonstrated a sensitivity of 90% (82.38 - 95.10%), compared to 48% (37.9 - 58.22%) for the PTP2019 model.

The PTP2013 model is favored, as it showed higher sensitivity and a tendency to overestimate risk, in contrast to the PTP2019 model, which exhibited a concerning underdiagnosis of CAD. Consequently, the methodological challenge of identifying the predictive model with the highest diagnostic performance remains, highlighting the need to develop a tailored prediction model for the local population. Competing Interest Statement The authors have declared no competing interest. Clinical Trial Our study is part of the observational branch, we analyzed two different prediction models against patient records from our institution. Funding Statement We did not receive funding in any form for this study. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Ethics committee of Fundación Santa Fe de Bogotá, on the 20th of May 2024 approved the protocol for the project "External Validation and Comparison of Two Clinical Prediction Models (PTP2013 and PTP2019) for Chest Pain in a Colombian Cohort" with the project code "SECEC-2024-079" prior to its initiation. Additionally, the study did not had to be notified to the Colombian regulatory authority for drug surveillance (INVIMA in Spanish). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes