Clinical and Economic Implications of Inconclusive Noninvasive Test Results in Stable Patients with Suspected Coronary Artery Disease: Insights from the PROMISE Trial

Akash Goyal, Neha Pagidipati, C. Larry Hill, Brooke Alhanti, James E. Udelson, Michael H. Picard, Patricia A. Pellikka, Udo Hoffmann, Daniel B. Mark, Pamela S. Douglas

Research output: Contribution to journalArticle

Abstract

Background: Inconclusive noninvasive tests complicate the care of patients with suspected coronary artery disease, but their prevalence and impact on management, outcomes, and costs are not well described. Methods: PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) patients were randomized to stress testing (n=4533) or computed tomographic angiography (CTA; n=4677). We assessed relationships between inconclusive results, subsequent testing, a composite outcome (death, myocardial infarction, or hospitalization for unstable angina), and healthcare expenditures. Results: Overall, 8.0% of tests were inconclusive (9.7% stress, 6.4% CTA). Compared with negative tests, inconclusive tests were more often referred to a second noninvasive test (stress: 14.6% versus 8.5%, odds ratio [OR], 1.91; CTA: 36.5% versus 8.4%, OR, 5.95; P<0.001) and catheterization (stress: 5.5% versus 2.4%, OR, 2.36; CTA: 23.4% versus 4.1%, OR, 6.49; P<0.001), and composite outcomes were higher for both inconclusive tests (stress: 3.7% versus 2.0%, hazard ratio, 1.81, P=0.034; CTA: 5.0% versus 2.2%, hazard ratio, 1.85; P=0.044) and positive tests (stress: 8.3% versus 2.0%, hazard ratio, 3.50; CTA: 9.2% versus 2.2%, hazard ratio, 3.66; P<0.001). Twenty-four-month costs were higher for inconclusive tests than negative tests by $2905 (stress) and $4030 (CTA). Conclusions: Among patients with stable chest pain undergoing a noninvasive test, inconclusive results occurred in 6% of CTA and 10% of stress tests. Compared with those with conclusive negative tests, individuals with inconclusive results more often underwent subsequent testing, had increased medical costs, and experienced worse outcomes. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01174550.

Original languageEnglish (US)
Article numbere009986
JournalCirculation: Cardiovascular Imaging
DOIs
StatePublished - Apr 1 2020

Keywords

  • computed tomography angiography
  • coronary artery disease
  • costs and cost analysis
  • exercise testing
  • mortality
  • prevalence

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Cardiology and Cardiovascular Medicine

Fingerprint Dive into the research topics of 'Clinical and Economic Implications of Inconclusive Noninvasive Test Results in Stable Patients with Suspected Coronary Artery Disease: Insights from the PROMISE Trial'. Together they form a unique fingerprint.

  • Cite this