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 Pellikka, Jean Claude Tardif, Matthew Budoff, George Nahhas, Benjamin Chow, Andrzej S. Kosinski, Kerry L. Lee, Pamela S. Douglas

Research output: Contribution to journalArticle

82 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; 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, P, 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 ; 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.
@article{83d61d85f0e2433a844d4c61bd449647,
title = "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)",
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.",
keywords = "coronary artery disease, diagnostic tests, routine, prognosis",
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 Patricia Pellikka 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.}",
year = "2017",
month = "6",
day = "13",
doi = "10.1161/CIRCULATIONAHA.116.024360",
language = "English (US)",
volume = "135",
pages = "2320--2332",
journal = "Circulation",
issn = "0009-7322",
publisher = "Lippincott Williams and Wilkins",
number = "24",

}

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

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

UR - http://www.scopus.com/inward/record.url?scp=85018682218&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85018682218&partnerID=8YFLogxK

U2 - 10.1161/CIRCULATIONAHA.116.024360

DO - 10.1161/CIRCULATIONAHA.116.024360

M3 - Article

C2 - 28389572

AN - SCOPUS:85018682218

VL - 135

SP - 2320

EP - 2332

JO - Circulation

JF - Circulation

SN - 0009-7322

IS - 24

ER -