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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In 2019 the European Society of Cardiology &#40;ESC&#41; updated its method for estimating the pre-test probability &#40;PTP&#41; of obstructive coronary artery disease &#40;CAD&#41; in the guidelines on chronic coronary syndromes&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; Lopes et al&#46; present a single-center cross-sectional study enrolling 320 consecutive patients with stable chest pain undergoing coronary computed tomography angiography &#40;CCTA&#41; for suspected CAD&#44; aiming to compare the performance of the new PTP method with the prediction model in the 2013 guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Using as reference standard the presence of obstructive coronary disease&#44; defined as &#8805;50&#37; stenosis on CCTA &#40;or invasive coronary angiography when it was performed subsequently&#41;&#44; the authors compared the two prediction models in terms of calibration&#44; discrimination and the ability to change the downstream diagnostic pathway&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Despite the important limitations of the study&#44; particularly the absence of coronary angiography &#40;and so of the defined gold standard&#41; in a proportion of patients with calcium score &#62;400 &#8211; in which the presence of obstructive CAD was directly assumed or confirmed according to subsequent functional tests&#44; if performed &#8211; this article further supports the adoption of the 2019 PTP estimation method&#46; According to the study results&#44; the updated 2019 prediction model provides a more accurate estimation of the PTP of obstructive CAD than the previous model&#58; while the 2013 model significantly overestimated the likelihood of obstructive CAD&#44; the updated 2019 method showed good calibration&#44; with a net reclassification improvement of 10&#37;&#44; and similar discriminative power&#46; Another potential advantage of the new PTP model &#8211; which was not addressed in this publication &#8211; is the incorporation of dyspnea as a discriminatory symptom of CAD&#44; enabling assessment of PTP in previously excluded patients&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Besides improving disease prediction&#44; adoption of the 2019 ESC guidelines will most certainly have a significant impact on the appropriate selection of non-invasive testing for the diagnosis of CAD&#46; As the authors correctly state&#44; the new guidelines not only updated the PTP model but have simultaneously lowered the threshold for testing&#44; aiming to keep false negatives below 5&#37;&#46; Taken together&#44; these new recommendations tend to emphasize the unique role of CCTA in CAD assessment&#44; based on its superior performance in ruling out CAD in populations with lower PTP&#46; It is now clear that a diagnosis of CAD should no longer be based solely on treadmill testing and catheterization or on other functional testing but should rather take advantage of the different methods available&#44; according to the different pre-test probabilities under study&#46; Technical developments and evidence accumulated in recent decades have supplied the necessary tools for a much more precise and personalized medicine and pushed guidelines forward&#46; However&#44; the bottleneck for guideline-driven quality medicine in CAD diagnosis&#44; at least in some European countries like Portugal&#44; seems to be the lack of availability and&#47;or reimbursement for the correct test&#46; In the name of quality of care&#44; current efforts should focus on removing these constraints&#44; in order to guide the appropriate management of patients with suspected CAD&#44; while avoiding exposure to unnecessary procedures and costs&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Quality studies like the one presented in this issue of the <span class="elsevierStyleItalic">Journal</span> by Lopes et al&#46; may provide a much-needed perspective on the real-world clinical impact of guideline changes and are therefore very welcome&#46; The authors should be congratulated for their work&#44; while readers and the medical community in general should feel encouraged to act in order to break down all the barriers that block the application of current guidelines&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Estimating the pre-test probability of coronary artery disease according to the ESC guidelines: Are we getting there?
Probabilidade pré-teste de doença coronária obstrutiva: o ajustar da mira!
Nuno Bettencourt
UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In 2019 the European Society of Cardiology &#40;ESC&#41; updated its method for estimating the pre-test probability &#40;PTP&#41; of obstructive coronary artery disease &#40;CAD&#41; in the guidelines on chronic coronary syndromes&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; Lopes et al&#46; present a single-center cross-sectional study enrolling 320 consecutive patients with stable chest pain undergoing coronary computed tomography angiography &#40;CCTA&#41; for suspected CAD&#44; aiming to compare the performance of the new PTP method with the prediction model in the 2013 guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Using as reference standard the presence of obstructive coronary disease&#44; defined as &#8805;50&#37; stenosis on CCTA &#40;or invasive coronary angiography when it was performed subsequently&#41;&#44; the authors compared the two prediction models in terms of calibration&#44; discrimination and the ability to change the downstream diagnostic pathway&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Despite the important limitations of the study&#44; particularly the absence of coronary angiography &#40;and so of the defined gold standard&#41; in a proportion of patients with calcium score &#62;400 &#8211; in which the presence of obstructive CAD was directly assumed or confirmed according to subsequent functional tests&#44; if performed &#8211; this article further supports the adoption of the 2019 PTP estimation method&#46; According to the study results&#44; the updated 2019 prediction model provides a more accurate estimation of the PTP of obstructive CAD than the previous model&#58; while the 2013 model significantly overestimated the likelihood of obstructive CAD&#44; the updated 2019 method showed good calibration&#44; with a net reclassification improvement of 10&#37;&#44; and similar discriminative power&#46; Another potential advantage of the new PTP model &#8211; which was not addressed in this publication &#8211; is the incorporation of dyspnea as a discriminatory symptom of CAD&#44; enabling assessment of PTP in previously excluded patients&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Besides improving disease prediction&#44; adoption of the 2019 ESC guidelines will most certainly have a significant impact on the appropriate selection of non-invasive testing for the diagnosis of CAD&#46; As the authors correctly state&#44; the new guidelines not only updated the PTP model but have simultaneously lowered the threshold for testing&#44; aiming to keep false negatives below 5&#37;&#46; Taken together&#44; these new recommendations tend to emphasize the unique role of CCTA in CAD assessment&#44; based on its superior performance in ruling out CAD in populations with lower PTP&#46; It is now clear that a diagnosis of CAD should no longer be based solely on treadmill testing and catheterization or on other functional testing but should rather take advantage of the different methods available&#44; according to the different pre-test probabilities under study&#46; Technical developments and evidence accumulated in recent decades have supplied the necessary tools for a much more precise and personalized medicine and pushed guidelines forward&#46; However&#44; the bottleneck for guideline-driven quality medicine in CAD diagnosis&#44; at least in some European countries like Portugal&#44; seems to be the lack of availability and&#47;or reimbursement for the correct test&#46; In the name of quality of care&#44; current efforts should focus on removing these constraints&#44; in order to guide the appropriate management of patients with suspected CAD&#44; while avoiding exposure to unnecessary procedures and costs&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Quality studies like the one presented in this issue of the <span class="elsevierStyleItalic">Journal</span> by Lopes et al&#46; may provide a much-needed perspective on the real-world clinical impact of guideline changes and are therefore very welcome&#46; The authors should be congratulated for their work&#44; while readers and the medical community in general should feel encouraged to act in order to break down all the barriers that block the application of current guidelines&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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