Comparison of Risk Assessment Strategies Recommended by the 2019 and 2024 European Society of Cardiology Guidelines in Patients With Stable Chest Pain: A Coronary Computed Tomography Angiography Study

Background: The European Society of Cardiology issued guidelines in 2019 and 2024 to help clinicians determine whether patients with stable chest pain (SCP) require advanced cardiovascular imaging testing (CIT). This study aimed to compare the safety and effectiveness of these evaluation strategies. Methods: A total of 17,612 symptomatic patients referred for coronary computed tomography angiography (CCTA) were included and followed over time. Each patient was classified into a deferral or referral group according to the 2019 and 2024 strategies, respectively. Obstructive coronary artery disease (CAD) was primarily defined as a lesion with ≥50% diameter stenosis on CCTA. Associations between major adverse cardiovascular events (MACEs) and the deferral and referral groups were evaluated using hazard ratios (HRs). Net reclassification improvement (NRI) and the number needed to test (NNT) to prevent unnecessary CIT were used to compare the two strategies. Results: Under the 2019 and 2024 strategies, 40% and 46% of patients, respectively, were categorized into deferral groups. These groups demonstrated a low prevalence of obstructive CAD (9.8% and 9.4%) and MACE (3.9% and 3.9%), suggesting that only limited intensive clinical follow-up was needed. Compared with the 2019 strategy, the 2024 strategy revealed a stronger association with MACEs (HR: 3.64 vs. 3.28) and a positive NRI (6.11%; p < 0.001), resulting in an NNT of 17. Conclusions: The 2024 strategy maintained a safety profile comparable to that of the 2019 strategy while potentially reducing unnecessary CIT in patients presenting with SCP suggestive of chronic coronary syndrome (CCS).