Diagnostic Strategies for the Evaluation of Chest Pain

Fordyce, Christopher B.; Newby, David E.; Douglas, Pamela S.

doi:10.1016/j.jacc.2015.11.055

Cited by 56 publications

(23 citation statements)

References 43 publications

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“…In order to understand the reasons for risk estimate imprecision we need to consider carefully the differences in patient populations between the PROMISE and SCOT-HEART trials. Such differences have previously been reported [16] , but specific areas of relevance to the current findings warrant mention. First, the improvement in discrimination seen with the SCOT-HEART population is likely to reflect the greater breadth of baseline risk which gives rise to a broader spread of the linear predictors within the validation cohort [17] .…”

Section: Discussionsupporting

confidence: 75%

Identification of patients with stable chest pain deriving minimal value from coronary computed tomography angiography: An external validation of the PROMISE minimal-risk tool

Adamson

Fordyce

McAllister

et al. 2018

International Journal of Cardiology

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BackgroundThe PROspective Multicenter Imaging Study for Evaluation of chest pain (PROMISE) minimal-risk tool was recently developed to identify patients with suspected stable angina at very low risk of coronary artery disease (CAD) and clinical events. We assessed the external validity of this tool within the context of the Scottish Computed Tomography of the HEART (SCOT-HEART) multicenter randomised controlled trial of patients with suspected stable angina due to coronary disease.MethodsThe minimal-risk tool was applied to 1764 patients with complete imaging and follow-up data. External validity was compared with the guideline-endorsed CAD Consortium (CADC) risk score and determined through tests of model discrimination and calibration.ResultsA total of 531 (30.1%, mean age 52.4 years, female 62.0%) patients were classified as minimal-risk. Compared to the remainder of the validation cohort, this group had lower estimated pre-test probability of coronary disease according to the CADC model (30.0% vs 47.0%, p < 0.001). The PROMISE minimal-risk tool improved discrimination compared with the CADC model (c-statistic 0.785 vs 0.730, p < 0.001) and was improved further following re-estimation of covariate coefficients (c-statistic 0.805, p < 0.001). Model calibration was initially poor (χ2 197.6, Hosmer-Lemeshow [HL] p < 0.001), with significant overestimation of probability of minimal risk, but improved significantly following revision of the PROMISE minimal-risk intercept and covariate coefficients (χ2 5.6, HL p = 0.692).Conclusion and relevanceDespite overestimating the probability of minimal-risk, the PROMISE minimal-risk tool outperforms the CADC model with regards to prognostic discrimination in patients with suspected stable angina, and may assist clinicians in decisions regarding non-invasive testing.Trial registrationClinicalTrials.gov identifier: NCT01149590

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Section: Discussionsupporting

confidence: 75%

Identification of patients with stable chest pain deriving minimal value from coronary computed tomography angiography: An external validation of the PROMISE minimal-risk tool

Adamson

Fordyce

McAllister

et al. 2018

International Journal of Cardiology

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“…This may account for why individuals presenting with chest pain classified as nonanginal comprised merely 11% within PROMISE compared with 41% in SCOT-HEART. In contrast, only 72% of patients within PROMISE described chest pain as the primary symptom compared with the entire SCOT-HEART cohort (10) , perhaps explaining the 2-fold greater prevalence of obstructive CAD in the latter, despite comprising a population at apparently lower cardiovascular risk, as determined by the Framingham score.…”

Section: Discussionmentioning

confidence: 95%

“…The intervention arm in both studies consisted of CCTA, which was compared with usual care. Details of cohort-specific inclusion and exclusion criteria have been previously described (10) . To confirm guideline utility in distinct clinical settings and across populations, the study cohorts were analyzed separately.…”

Section: Methodsmentioning

confidence: 99%

Comparison of International Guidelines for Assessment of Suspected Stable Angina

Adamson

Newby

Hill

et al. 2018

JACC: Cardiovascular Imaging

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ObjectivesThis study sought to compare the performance of major guidelines for the assessment of stable chest pain including risk-based (American College of Cardiology/American Heart Association and European Society of Cardiology) and symptom-focused (National Institute for Health and Care Excellence) strategies.BackgroundAlthough noninvasive testing is not recommended in low-risk individuals with stable chest pain, guidelines recommend differing approaches to defining low-risk patients.MethodsPatient-level data were obtained from the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) and SCOT-HEART (Scottish Computed Tomography of the Heart) trials. Pre-test probability was determined and patients dichotomized into low-risk and intermediate-high–risk groups according to each guideline’s definitions. The primary endpoint was obstructive coronary artery disease on coronary computed tomography angiography. Secondary endpoints were coronary revascularization at 90 days and cardiovascular death or nonfatal myocardial infarction up to 3 years.ResultsIn total, 13,773 patients were included of whom 6,160 had coronary computed tomography angiography. The proportions of patients identified as low risk by the American College of Cardiology/American Heart Association, European Society of Cardiology, and National Institute for Health and Care Excellence guidelines, respectively, were 2.5%, 2.5%, and 10.0% within PROMISE, and 14.0%, 19.8%, and 38.4% within SCOT-HEART. All guidelines identified lower rates of obstructive coronary artery disease in low- versus intermediate-high–risk patients with a negative predictive value of ≥0.90. Compared with low-risk groups, all intermediate-high–risk groups had greater risks of coronary revascularization (odds ratio [OR]: 2.2 to 24.1) and clinical outcomes (OR: 1.84 to 5.8).ConclusionsCompared with risk-based guidelines, symptom-focused assessment identifies a larger group of low-risk chest pain patients potentially deriving limited benefit from noninvasive testing. (Scottish Computed Tomography of the Heart Trial [SCOT-HEART]; NCT01149590; Prospective Multicenter Imaging Study for Evaluation of Chest Pain [PROMISE]; NCT01174550)

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“…Coronary computed tomography angiography is now considered a reasonable or preferred first line investigation for patients with suspected CAD, 12–14 as studies have suggested improved clinical outcomes for patients managed based on initial CCTA rather than alternative non-invasive tests. 4 While, CCTA has been proven to be an effective diagnostic tool, there remain concerns regarding fairly high rates of downstream ICA and resource utilization as well as the lack of physiological information available to guide treatment decision-making.…”

Section: Discussionmentioning

confidence: 99%

Real-world clinical utility and impact on clinical decision-making of coronary computed tomography angiography-derived fractional flow reserve: lessons from the ADVANCE Registry

Fairbairn

Nieman

Akasaka

et al. 2018

European Heart Journal

247

146

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AimsNon-invasive assessment of stable chest pain patients is a critical determinant of resource utilization and clinical outcomes. Increasingly coronary computed tomography angiography (CCTA) with selective CCTA-derived fractional flow reserve (FFRCT) is being used. The ADVANCE Registry, is a large prospective examination of using a CCTA and FFRCT diagnostic pathway in real-world settings, with the aim of determining the impact of this pathway on decision-making, downstream invasive coronary angiography (ICA), revascularization, and major adverse cardiovascular events (MACE).Methods and resultsA total of 5083 patients with symptoms concerning for coronary artery disease (CAD) and atherosclerosis on CCTA were enrolled at 38 international sites from 15 July 2015 to 20 October 2017. Demographics, symptom status, CCTA and FFRCT findings, treatment plans, and 90 days outcomes were recorded. The primary endpoint of reclassification between core lab CCTA alone and CCTA plus FFRCT-based management plans occurred in 66.9% [confidence interval (CI): 64.8–67.6] of patients. Non-obstructive coronary disease was significantly lower in ICA patients with FFRCT ≤0.80 (14.4%) compared to patients with FFRCT >0.80 (43.8%, odds ratio 0.19, CI: 0.15–0.25, P < 0.001). In total, 72.3% of subjects undergoing ICA with FFRCT ≤0.80 were revascularized. No death/myocardial infarction (MI) occurred within 90 days in patients with FFRCT >0.80 (n = 1529), whereas 19 (0.6%) MACE [hazard ratio (HR) 19.75, CI: 1.19–326, P = 0.0008] and 14 (0.3%) death/MI (HR 14.68, CI 0.88–246, P = 0.039) occurred in subjects with an FFRCT ≤0.80.ConclusionsIn a large international multicentre population, FFRCT modified treatment recommendation in two-thirds of subjects as compared to CCTA alone, was associated with less negative ICA, predicted revascularization, and identified subjects at low risk of adverse events through 90 days.

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Diagnostic Strategies for the Evaluation of Chest Pain

Cited by 56 publications

References 43 publications

Identification of patients with stable chest pain deriving minimal value from coronary computed tomography angiography: An external validation of the PROMISE minimal-risk tool

Identification of patients with stable chest pain deriving minimal value from coronary computed tomography angiography: An external validation of the PROMISE minimal-risk tool

Comparison of International Guidelines for Assessment of Suspected Stable Angina

Real-world clinical utility and impact on clinical decision-making of coronary computed tomography angiography-derived fractional flow reserve: lessons from the ADVANCE Registry

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