# Sex Differences in Two International Guidelines for Assessing Obstructive Coronary Artery Disease in Symptomatic Outpatients by Coronary Computed Tomographic Angiography

## TL;DR

This study compares two guidelines for assessing heart disease in outpatients, finding that the European Society of Cardiology guidelines perform better and treat men and women differently.

## Contribution

The study evaluates sex-specific performance differences between two international guidelines for coronary artery disease risk assessment.

## Key findings

- The ESC guidelines showed higher predictive accuracy for coronary artery disease compared to the NICE guidelines.
- The ESC guidelines reclassified more women into low-risk groups, reducing unnecessary testing.
- The ESC guidelines improved risk assessment for both men and women with a positive net reclassification improvement.

## Abstract

Low-risk individuals are unlikely to benefit from
noninvasive testing, and women tend to have a lower prevalence of coronary artery
disease (CAD). This study compared the performance of two current guidelines that
differ by sex to assess s a'q's't chest pain outpatients, including symptom-based
(2016 National Institute for Health and Care Excellence, NICE) and risk-based
strategies (2019 European Society of Cardiology, ESC).

A total
of 542 outpatients referred for coronary computed tomography angiography (CCTA)
at a single-centre were retrospectively included in this study. A risk assessment
was calculated for each outpatient according to the two guidelines. Patients were
classified into low and high-risk groups according to each strategy. The presence
of coronary artery disease was the endpoint. Net reclassification improvement
(NRI) was used to assess the performance of the two strategies.

The prevalence of CAD was 27%. The sensitivity, specificity, positive predictive
value and negative predictive value for ESC and NICE were 90.4%, 54.3%, 42.2%,
93.9% and 78.8%, 35.6%, 31.1% and 82.0% respectively. Compare to NICE, the
NRI for ESC were 30.32%. The ESC guidelines classified 55.56% of women and
28.14% of men into the low-risk group. The ESC guidelines had a higher
predictive value for coronary artery disease compared to the NICE guidelines,
with a positive NRI in men (15.55%) and women (34.46%) respectively.

The ESC guidelines offered a more accurate calculation of
risk assessment than the NICE guidelines. Patient sex influenced applying the
recent ESC guidelines, which would result in a significant decrease in
inappropriate testing of women but an increase in appropriate noninvasive testing
of men.