Diamond and Forrester Pretest Probability for CAD

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Clinical Use

Estimate the pretest probability for obstructive coronary artery disease in patients with stable chest pain

More Info

The Diamond and Forrester model1 has been used to estimate the pretest probability of coronary artery disease in patients presenting with stable chest pain over the past 30 years. However, more recent studies2 have demonstrated that the Diamond and Forrester model tends to overestimate the pre-test probability of CAD.

The model uses age, gender and characteristic of chest pain to predict the presence of coronary artery disease as follows:

 

Chest pain characteristics
  • Substernal chest pain
  • Exertional chest pain
  • Chest pain relieved with rest

 

Interpretation

Typical Angina: 3 criteria from above

  • Age 30-39: 76% likelihood (intermediate) in men and 26% in women (intermediate)
  • Age 40-49: 87% likelihood (high) in men and 55% in women (intermediate)
  • Age 50-59: 93% likelihood (high) in men and 73% in women (intermediate)
  • Age 60-69: 94% likelihood (high) in men and 86% in women (high)

Atypical Angina: 2 criteria from above

  • Age 30-39: 34% likelihood (intermediate) in men and 12% in women (low)
  • Age 40-49: 51% likelihood (intermediate) in men and 22% in women (low)
  • Age 50-59: 65% likelihood (intermediate) in men and 31% in women (intermediate)
  • Age 60-69: 72% likelihood (intermediate) in men and 51% in women (intermediate)

Non-Anginal Chest Pain: 1 criteria from above

  • Age 30-39: 4% likelihood (low) in men and 2% in women (low)
  • Age 40-49: 13% likelihood (intermediate) in men and 3% in women (low)
  • Age 50-59: 20% likelihood (intermediate) in men and 7% in women (low)
  • Age 60-69: 27% likelihood (intermediate) in men and 14% in women (intermediate)

Asymptomatic

  • Risk is low to very low for both men and women

References

1Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med. 1979 Jun 14;300(24):1350-8. Abstract
2Genders TS et al. CAD Consortium Prediction model to estimate presence of coronary artery disease: retrospective pooled analysis of existing cohorts.
BMJ. 2012;344:e3485 Abstract

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Developer: Sirikarn Napan, MD, FACC