More Accurate Prediction of the Pretest Probability of Cardiovascular Disease with European Risk Score


Am Fam Physician. 2017 May 15;95(10):online.

Clinical Question

How accurately do the European Society of Cardiology scores predict the likelihood of cardiovascular disease compared with the older Diamond-Forrester score?

Bottom Line

The European approach to determining the pretest likelihood of coronary artery disease (CAD) in patients with chest pain is superior to that of the Diamond-Forrester approach recommended by U.S. guidelines, and will result in less need for immediate invasive treatment. It will identify more persons who are low risk and do not require further evaluation. The risk calculator is available at http://bit.ly/2je8FBc. (Level of Evidence = 1b)


Current guidelines from the American College of Cardiology and the American Heart Association recommend the use of the familiar Diamond-Forrester classification system to determine the pretest likelihood of CAD. It uses age, sex, and the type of angina (nonanginal, atypical, and typical) to place patients into risk groups for angina. However, the Diamond-Forrester system was developed with data from the 1970s, and much has changed in how we evaluate patients and manage chest pain. This includes changes in the management of risk factors, advances in treatment, and greater awareness of patients that should seek prompt evaluation for chest pain. The European Society of Cardiology has created a modified version of the Diamond-Forrester system that uses the same clinical variables (age, sex, angina), but was developed using contemporary data. They also created an enhanced version that adds additional risk factor variables.

In this study, the authors identified 2,274 patients without known cardiovascular disease who were referred for coronary computed tomographic angiography. Based on the U.S. guidelines, patients with a probability of less than 5% are classified as low risk and do not need further testing, those with a probability of 5% to 70% should undergo noninvasive testing, and those with a probability greater than 70% should undergo invasive angi

POEMs (patient-oriented evidence that matters) are provided by EssentialEvidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com. Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see http://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=oxford.

To subscribe to a free podcast of these and other POEMs that appear in AFP, search in iTunes for “POEM of the Week” or go to http://goo.gl/3niWXb.

This series is coordinated by Sumi Sexton, MD, Associate Deputy Editor.

A collection of POEMs published in AFP is available at https://www.aafp.org/afp/poems.



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May 15, 2018

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