Prognostic Value of Noninvasive Cardiovascular Testing in Patients with Stable Chest Pain: Insights from the PROMISE Trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain)

Udo Hoffmann, Maros Ferencik, James E. Udelson, Michael H. Picard, Quynh A. Truong, Manesh R. Patel, Megan Huang, Michael Pencina, Daniel B. Mark, John F. Heitner, Christopher B. Fordyce, Patricia A. Pellikka, Jean Claude Tardif, Matthew Budoff, George Nahhas, Benjamin Chow, Andrzej S. Kosinski, Kerry L. Lee, Pamela S. Douglas

    Research output: Contribution to journalArticle

    75 Citations (Scopus)

    Abstract

    Background: Optimal management of patients with stable chest pain relies on the prognostic information provided by noninvasive cardiovascular testing, but there are limited data from randomized trials comparing anatomic with functional testing. Methods: In the PROMISE trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain), patients with stable chest pain and intermediate pretest probability for obstructive coronary artery disease (CAD) were randomly assigned to functional testing (exercise electrocardiography, nuclear stress, or stress echocardiography) or coronary computed tomography angiography (CTA). Site-based diagnostic test reports were classified as normal or mildly, moderately, or severely abnormal. The primary end point was death, myocardial infarction, or unstable angina hospitalizations over a median follow-up of 26.1 months. Results: Both the prevalence of normal test results and incidence rate of events in these patients were significantly lower among 4500 patients randomly assigned to CTA in comparison with 4602 patients randomly assigned to functional testing (33.4% versus 78.0%, and 0.9% versus 2.1%, respectively; both P<0.001). In CTA, 54.0% of events (n=74/137) occurred in patients with nonobstructive CAD (1%-69% stenosis). Prevalence of obstructive CAD and myocardial ischemia was low (11.9% versus 12.7%, respectively), with both findings having similar prognostic value (hazard ratio, 3.74; 95% confidence interval [CI], 2.60-5.39; and 3.47; 95% CI, 2.42-4.99). When test findings were stratified as mildly, moderately, or severely abnormal, hazard ratios for events in comparison with normal tests increased proportionally for CTA (2.94, 7.67, 10.13; all P<0.001) but not for corresponding functional testing categories (0.94 [P=0.87], 2.65 [P=0.001], 3.88 [P<0.001]). The discriminatory ability of CTA in predicting events was significantly better than functional testing (c-index, 0.72; 95% CI, 0.68-0.76 versus 0.64; 95% CI, 0.59-0.69; P=0.04). If 2714 patients with at least an intermediate Framingham Risk Score (>10%) who had a normal functional test were reclassified as being mildly abnormal, the discriminatory capacity improved to 0.69 (95% CI, 0.64-0.74). Conclusions: Coronary CTA, by identifying patients at risk because of nonobstructive CAD, provides better prognostic information than functional testing in contemporary patients who have stable chest pain with a low burden of obstructive CAD, myocardial ischemia, and events.

    Original languageEnglish (US)
    Pages (from-to)2320-2332
    Number of pages13
    JournalCirculation
    Volume135
    Issue number24
    DOIs
    StatePublished - Jun 13 2017

    Fingerprint

    Chest Pain
    Multicenter Studies
    Coronary Artery Disease
    Stress Echocardiography
    Unstable Angina
    Routine Diagnostic Tests
    Myocardial Ischemia
    Electrocardiography
    Hospitalization
    Myocardial Infarction
    Exercise
    Incidence
    Computed Tomography Angiography

    Keywords

    • coronary artery disease
    • diagnostic tests, routine
    • prognosis

    ASJC Scopus subject areas

    • Cardiology and Cardiovascular Medicine
    • Physiology (medical)

    Cite this

    Prognostic Value of Noninvasive Cardiovascular Testing in Patients with Stable Chest Pain : Insights from the PROMISE Trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain). / Hoffmann, Udo; Ferencik, Maros; Udelson, James E.; Picard, Michael H.; Truong, Quynh A.; Patel, Manesh R.; Huang, Megan; Pencina, Michael; Mark, Daniel B.; Heitner, John F.; Fordyce, Christopher B.; Pellikka, Patricia A.; Tardif, Jean Claude; Budoff, Matthew; Nahhas, George; Chow, Benjamin; Kosinski, Andrzej S.; Lee, Kerry L.; Douglas, Pamela S.

    In: Circulation, Vol. 135, No. 24, 13.06.2017, p. 2320-2332.

    Research output: Contribution to journalArticle

    Hoffmann, U, Ferencik, M, Udelson, JE, Picard, MH, Truong, QA, Patel, MR, Huang, M, Pencina, M, Mark, DB, Heitner, JF, Fordyce, CB, Pellikka, PA, Tardif, JC, Budoff, M, Nahhas, G, Chow, B, Kosinski, AS, Lee, KL & Douglas, PS 2017, 'Prognostic Value of Noninvasive Cardiovascular Testing in Patients with Stable Chest Pain: Insights from the PROMISE Trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain)', Circulation, vol. 135, no. 24, pp. 2320-2332. https://doi.org/10.1161/CIRCULATIONAHA.116.024360
    Hoffmann, Udo ; Ferencik, Maros ; Udelson, James E. ; Picard, Michael H. ; Truong, Quynh A. ; Patel, Manesh R. ; Huang, Megan ; Pencina, Michael ; Mark, Daniel B. ; Heitner, John F. ; Fordyce, Christopher B. ; Pellikka, Patricia A. ; Tardif, Jean Claude ; Budoff, Matthew ; Nahhas, George ; Chow, Benjamin ; Kosinski, Andrzej S. ; Lee, Kerry L. ; Douglas, Pamela S. / Prognostic Value of Noninvasive Cardiovascular Testing in Patients with Stable Chest Pain : Insights from the PROMISE Trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain). In: Circulation. 2017 ; Vol. 135, No. 24. pp. 2320-2332.
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    abstract = "Background: Optimal management of patients with stable chest pain relies on the prognostic information provided by noninvasive cardiovascular testing, but there are limited data from randomized trials comparing anatomic with functional testing. Methods: In the PROMISE trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain), patients with stable chest pain and intermediate pretest probability for obstructive coronary artery disease (CAD) were randomly assigned to functional testing (exercise electrocardiography, nuclear stress, or stress echocardiography) or coronary computed tomography angiography (CTA). Site-based diagnostic test reports were classified as normal or mildly, moderately, or severely abnormal. The primary end point was death, myocardial infarction, or unstable angina hospitalizations over a median follow-up of 26.1 months. Results: Both the prevalence of normal test results and incidence rate of events in these patients were significantly lower among 4500 patients randomly assigned to CTA in comparison with 4602 patients randomly assigned to functional testing (33.4{\%} versus 78.0{\%}, and 0.9{\%} versus 2.1{\%}, respectively; both P<0.001). In CTA, 54.0{\%} of events (n=74/137) occurred in patients with nonobstructive CAD (1{\%}-69{\%} stenosis). Prevalence of obstructive CAD and myocardial ischemia was low (11.9{\%} versus 12.7{\%}, respectively), with both findings having similar prognostic value (hazard ratio, 3.74; 95{\%} confidence interval [CI], 2.60-5.39; and 3.47; 95{\%} CI, 2.42-4.99). When test findings were stratified as mildly, moderately, or severely abnormal, hazard ratios for events in comparison with normal tests increased proportionally for CTA (2.94, 7.67, 10.13; all P<0.001) but not for corresponding functional testing categories (0.94 [P=0.87], 2.65 [P=0.001], 3.88 [P<0.001]). The discriminatory ability of CTA in predicting events was significantly better than functional testing (c-index, 0.72; 95{\%} CI, 0.68-0.76 versus 0.64; 95{\%} CI, 0.59-0.69; P=0.04). If 2714 patients with at least an intermediate Framingham Risk Score (>10{\%}) who had a normal functional test were reclassified as being mildly abnormal, the discriminatory capacity improved to 0.69 (95{\%} CI, 0.64-0.74). Conclusions: Coronary CTA, by identifying patients at risk because of nonobstructive CAD, provides better prognostic information than functional testing in contemporary patients who have stable chest pain with a low burden of obstructive CAD, myocardial ischemia, and events.",
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    author = "Udo Hoffmann and Maros Ferencik and Udelson, {James E.} and Picard, {Michael H.} and Truong, {Quynh A.} and Patel, {Manesh R.} and Megan Huang and Michael Pencina and Mark, {Daniel B.} and Heitner, {John F.} and Fordyce, {Christopher B.} and Pellikka, {Patricia A.} and Tardif, {Jean Claude} and Matthew Budoff and George Nahhas and Benjamin Chow and Kosinski, {Andrzej S.} and Lee, {Kerry L.} and Douglas, {Pamela S.}",
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    TY - JOUR

    T1 - Prognostic Value of Noninvasive Cardiovascular Testing in Patients with Stable Chest Pain

    T2 - Insights from the PROMISE Trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain)

    AU - Hoffmann, Udo

    AU - Ferencik, Maros

    AU - Udelson, James E.

    AU - Picard, Michael H.

    AU - Truong, Quynh A.

    AU - Patel, Manesh R.

    AU - Huang, Megan

    AU - Pencina, Michael

    AU - Mark, Daniel B.

    AU - Heitner, John F.

    AU - Fordyce, Christopher B.

    AU - Pellikka, Patricia A.

    AU - Tardif, Jean Claude

    AU - Budoff, Matthew

    AU - Nahhas, George

    AU - Chow, Benjamin

    AU - Kosinski, Andrzej S.

    AU - Lee, Kerry L.

    AU - Douglas, Pamela S.

    PY - 2017/6/13

    Y1 - 2017/6/13

    N2 - Background: Optimal management of patients with stable chest pain relies on the prognostic information provided by noninvasive cardiovascular testing, but there are limited data from randomized trials comparing anatomic with functional testing. Methods: In the PROMISE trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain), patients with stable chest pain and intermediate pretest probability for obstructive coronary artery disease (CAD) were randomly assigned to functional testing (exercise electrocardiography, nuclear stress, or stress echocardiography) or coronary computed tomography angiography (CTA). Site-based diagnostic test reports were classified as normal or mildly, moderately, or severely abnormal. The primary end point was death, myocardial infarction, or unstable angina hospitalizations over a median follow-up of 26.1 months. Results: Both the prevalence of normal test results and incidence rate of events in these patients were significantly lower among 4500 patients randomly assigned to CTA in comparison with 4602 patients randomly assigned to functional testing (33.4% versus 78.0%, and 0.9% versus 2.1%, respectively; both P<0.001). In CTA, 54.0% of events (n=74/137) occurred in patients with nonobstructive CAD (1%-69% stenosis). Prevalence of obstructive CAD and myocardial ischemia was low (11.9% versus 12.7%, respectively), with both findings having similar prognostic value (hazard ratio, 3.74; 95% confidence interval [CI], 2.60-5.39; and 3.47; 95% CI, 2.42-4.99). When test findings were stratified as mildly, moderately, or severely abnormal, hazard ratios for events in comparison with normal tests increased proportionally for CTA (2.94, 7.67, 10.13; all P<0.001) but not for corresponding functional testing categories (0.94 [P=0.87], 2.65 [P=0.001], 3.88 [P<0.001]). The discriminatory ability of CTA in predicting events was significantly better than functional testing (c-index, 0.72; 95% CI, 0.68-0.76 versus 0.64; 95% CI, 0.59-0.69; P=0.04). If 2714 patients with at least an intermediate Framingham Risk Score (>10%) who had a normal functional test were reclassified as being mildly abnormal, the discriminatory capacity improved to 0.69 (95% CI, 0.64-0.74). Conclusions: Coronary CTA, by identifying patients at risk because of nonobstructive CAD, provides better prognostic information than functional testing in contemporary patients who have stable chest pain with a low burden of obstructive CAD, myocardial ischemia, and events.

    AB - Background: Optimal management of patients with stable chest pain relies on the prognostic information provided by noninvasive cardiovascular testing, but there are limited data from randomized trials comparing anatomic with functional testing. Methods: In the PROMISE trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain), patients with stable chest pain and intermediate pretest probability for obstructive coronary artery disease (CAD) were randomly assigned to functional testing (exercise electrocardiography, nuclear stress, or stress echocardiography) or coronary computed tomography angiography (CTA). Site-based diagnostic test reports were classified as normal or mildly, moderately, or severely abnormal. The primary end point was death, myocardial infarction, or unstable angina hospitalizations over a median follow-up of 26.1 months. Results: Both the prevalence of normal test results and incidence rate of events in these patients were significantly lower among 4500 patients randomly assigned to CTA in comparison with 4602 patients randomly assigned to functional testing (33.4% versus 78.0%, and 0.9% versus 2.1%, respectively; both P<0.001). In CTA, 54.0% of events (n=74/137) occurred in patients with nonobstructive CAD (1%-69% stenosis). Prevalence of obstructive CAD and myocardial ischemia was low (11.9% versus 12.7%, respectively), with both findings having similar prognostic value (hazard ratio, 3.74; 95% confidence interval [CI], 2.60-5.39; and 3.47; 95% CI, 2.42-4.99). When test findings were stratified as mildly, moderately, or severely abnormal, hazard ratios for events in comparison with normal tests increased proportionally for CTA (2.94, 7.67, 10.13; all P<0.001) but not for corresponding functional testing categories (0.94 [P=0.87], 2.65 [P=0.001], 3.88 [P<0.001]). The discriminatory ability of CTA in predicting events was significantly better than functional testing (c-index, 0.72; 95% CI, 0.68-0.76 versus 0.64; 95% CI, 0.59-0.69; P=0.04). If 2714 patients with at least an intermediate Framingham Risk Score (>10%) who had a normal functional test were reclassified as being mildly abnormal, the discriminatory capacity improved to 0.69 (95% CI, 0.64-0.74). Conclusions: Coronary CTA, by identifying patients at risk because of nonobstructive CAD, provides better prognostic information than functional testing in contemporary patients who have stable chest pain with a low burden of obstructive CAD, myocardial ischemia, and events.

    KW - coronary artery disease

    KW - diagnostic tests, routine

    KW - prognosis

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