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Risk tool may help patients with stable chest pain avoid noninvasive testing
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A user-friendly, point-of-care decision support calculator identified patients with stable chest pain referred for noninvasive testing who were likely to have a normal test result and no clinical events, according to new data from the PROMISE trial.
Christopher B. Fordyce, MD, MHS, MSc, from the division of cardiology at the University of British Columbia in Vancouver, Canada, and colleagues used pretest clinical characteristics, including risk factor profile, symptom characteristics and lipid values to create the tool.
The researchers performed a secondary analysis of the PROMISE trial, which was a randomized, pragmatic comparative effectiveness trial.
The patients in the trial were stable, symptomatic outpatients. All patients had no known CAD and were referred for noninvasive testing. They were evaluated at 193 different North American sites and were randomly assigned to coronary CTA or functional testing.
The tool developed by the researchers was internally validated from July 2010 to September 2013. A total of 4,631 patients who received coronary CTA for an initial test were included in the validation. The patients had a median follow-up of 25 months. A minimal-risk cohort consisted of 1,243 patients (26.8%).
Minimal-risk model
The researchers correlated normal coronary CTA results and no clinical events with 10 clinical variables to form the final minimal-risk model. The variables were: younger age; female sex; racial or ethnic minority; no history of hypertension, diabetes or dyslipidemia; family history of premature CAD; never smoking; symptoms unrelated to physical or mental stress; and higher HDL level.
When the model was applied to the entire PROMISE cohort, for the patients in the 10th decile of minimal risk, it was associated with the lowest rates of severely abnormal test results (1.3% for those assigned coronary CTA; 5.6% for those assigned functional testing) and CV death or MI (0.5% at median of 25 months).
“If a high likelihood of a normal test result and low clinical event rate is identified, clinicians could consider, including through shared decision making, a strategy of deferred testing for such patients because the benefit and value of testing are likely to be low,” Fordyce and colleagues wrote.
Accurate risk assessment
In a related editorial, Alan Rozanski, MD, of the division of cardiology at Mount Sinai St. Luke’s Hospital. New York, and Daniel S. Berman, MD, from the departments of imaging and medicine at Cedars-Sinai Medical Center, Los Angeles, and a member of the Cardiology Today Editorial Board, wrote: “Knowing which pathway to use in the selection of a testing strategy will depend on the accurate assessment of the baseline risk. Fordyce et al have provided an approach that defines one end of the spectrum and the CONFIRM and European Society of Cardiology scores provide others across the spectrum of risk. The ideal pretest risk-assessment tool remains to be described and validated.” – by Suzanne Reist
Disclosure : Berman, Fordyce and Rozanski report no relevant financial disclosures. Please see the full study for a list of the other researchers’ relevant financial disclosures.
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