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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).

Publication ,  Journal Article
Hoffmann, U; Ferencik, M; Udelson, JE; Picard, MH; Truong, QA; Patel, MR; Huang, M; Pencina, M; Mark, DB; Heitner, JF; Fordyce, CB; Budoff, M ...
Published in: Circulation
June 13, 2017

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. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01174550.

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Published In

Circulation

DOI

EISSN

1524-4539

Publication Date

June 13, 2017

Volume

135

Issue

24

Start / End Page

2320 / 2332

Location

United States

Related Subject Headings

  • Tomography, X-Ray Computed
  • Prospective Studies
  • Prognosis
  • Middle Aged
  • Male
  • Humans
  • Follow-Up Studies
  • Female
  • Exercise Test
  • Echocardiography, Stress
 

Citation

APA
Chicago
ICMJE
MLA
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Hoffmann, U., Ferencik, M., Udelson, J. E., Picard, M. H., Truong, Q. A., Patel, M. R., … PROMISE Investigators, . (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, 135(24), 2320–2332. https://doi.org/10.1161/CIRCULATIONAHA.116.024360
Hoffmann, Udo, Maros Ferencik, James E. Udelson, Michael H. Picard, Quynh A. Truong, Manesh R. Patel, Megan Huang, et al. “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 135, no. 24 (June 13, 2017): 2320–32. https://doi.org/10.1161/CIRCULATIONAHA.116.024360.
Hoffmann, Udo, et al. “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, June 2017, pp. 2320–32. Pubmed, doi:10.1161/CIRCULATIONAHA.116.024360.
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 J-C, Budoff M, Nahhas G, Chow B, Kosinski AS, Lee KL, Douglas PS, PROMISE Investigators. 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. 2017 Jun 13;135(24):2320–2332.

Published In

Circulation

DOI

EISSN

1524-4539

Publication Date

June 13, 2017

Volume

135

Issue

24

Start / End Page

2320 / 2332

Location

United States

Related Subject Headings

  • Tomography, X-Ray Computed
  • Prospective Studies
  • Prognosis
  • Middle Aged
  • Male
  • Humans
  • Follow-Up Studies
  • Female
  • Exercise Test
  • Echocardiography, Stress