Validity of the 2019 European Society of Cardiology Pre-Test Probability (2019 ESC-PTP) for predicting obstructive coronary artery disease among Malaysians

The 2019 European Society of Cardiology (ESC) guideline introduced a pre-test probability (PTP) tool to estimate the likelihood of obstructive coronary artery disease (CAD). Its performance has not been validated in the Malaysian population. This study aimed to validate this tool in this setting. A cross-sectional study was conducted from June 2023 to May 2024. PTP scores were calculated using the 2019 ESC-PTP tool and stratified as low (≤ 5%), moderate (> 5%–15%), and high (> 15%) risk. For diagnostic accuracy analysis, low scores were considered negative, while moderate-to-high scores were grouped as positive tests. Reference standards were ≥ 50% luminal stenosis on invasive coronary angiography (ICA), or a Coronary Artery Disease Reporting and Data System (CAD-RADS) 2.0 score of ≥ 3 on coronary computed tomography angiography (CCTA). Diagnostic performance was evaluated using sensitivity, specificity, positive and negative predictive values (PPV, NPV), likelihood ratios (PLR, NLR), area under the receiver operating characteristic curve (AUC), and overall diagnostic accuracy. Among 194 participants, 110 (56.7%) had obstructive CAD. The 2019 ESC-PTP tool demonstrated sensitivity of 95.5% (95% CI: 90.5–98.3) and specificity of 25.0% (95% CI: 16.6–34.9). PPV was 62.5% (95% CI: 55.0–69.6), NPV 80.8% (95% CI: 63.1–92.6), PLR 1.27 (95% CI: 1.11–1.45) and NLR 0.18 (95% CI: 0.07–0.46). The AUC was 0.794 (95% CI: 0.732–0.857) with an overall accuracy of 64.9% (95% CI: 58.2–71.7). The 2019 ESC-PTP tool demonstrates high sensitivity, making it reliable for excluding obstructive CAD in low-risk patients. Its limited specificity restricts its role in confirming disease, highlighting the need for further testing in moderate-to-high risk groups.