Abstract 18053: Prognostic Value of Anatomic versus Functional Diagnostic Testing in Symptomatic Patients With Suspected CAD: The PROMISE Trial (PROspective Multicenter Imaging Study for Evaluation of Chest Pain)
Introduction: Symptoms suggestive of coronary artery disease (CAD) are common, but no randomized comparison of the prognostic value of coronary computed tomographic angiography (CTA) vs. functional testing has been performed.
Methods: Patients (10,003) with suspected CAD were randomized to functional testing (exercise ECG, nuclear stress, or stress echo) or CTA. Site-based diagnostic test reports were classified as normal or mildly, moderately, or severely abnormal. Cox proportional hazards models assessed the relationship of test results to a composite of time to death, myocardial infarction, or unstable angina, and the discriminatory ability of the two tests was compared using the C-index. Adjusted HRs for events in patients with abnormal vs. normal test results were determined for CTA and functional testing.
Results: Overall, 4516 patients received CTA and 4572 functional testing as the randomized diagnostic test. The proportions of normal, mild, moderate, and severe abnormalities on CTA were 33.3%, 42.7%, 10.0%, and 14.0%, respectively, and for functional testing 78.9%, 8.5%, 4.2%, and 8.4% (P=0.001). Event rates over 26.0 months’ (IQR 18.0, 34.4) follow-up were similar: CTA 137/4516 (3.0%) vs. functional 132/4572 (2.9%). Compared to patients with normal CTAs, those with abnormal CTAs had increasing HRs for events with increasingly severe abnormalities, while only patients with moderate and severely abnormal functional testing had an increased HR for events (Figure). The probability of having an event given a normal test result was lower for CTA compared to functional testing (0.9% vs. 2.2%; HR 0.47 [95% CI 0.26, 0.83]; P=0.009), but not significantly different for other test strata. The overall prognostic performance (C-index) of CTA vs. functional testing was 0.72 (0.68, 0.76) vs. 0.64 (0.60, 0.69); P=0.022 (see KM curves in Figure).
Conclusions: In symptomatic patients with suspected CAD, CTA has better prognostic value than functional testing.
- coronary artery disease
- computed tomography
- stress echocardiography
- heart function tests
Author Disclosures: U. Hoffmann: Research Grant; Significant; American College of Radiology Imaging Network, HeartFlow, Siemens Healthcare. M. Ferencik: Research Grant; Significant; AHA Fellow to Faculty Award. J.E. Udelson: None. M.H. Picard: None. J. Heitner: None. M.R. Patel: Research Grant; Significant; HeartFlow, Jansen, Johnson & Johnson, Astra Zeneca, AHRQ. Consultant/Advisory Board; Modest; AstraZeneca, Bayer, Otsuka. M. Huang: None. M. Pencina: Consultant/Advisory Board; Modest; Theracos. D.B. Mark: Research Grant; Significant; Eli Lilly, Bristol-Myers Squibb, Gilead Sciences, AGA Medical, Merck, Oxygen Therapeutics, AstraZeneca. Consultant/Advisory Board; Modest; Medtronic, CardioDx, St. Jude Medical. C.B. Fordyce: None. J. Tardif: None. M. Budoff: Research Grant; Significant; GE. G. Nahhas: Other; Significant; Johnson & Johnson. B. Chow: Research Grant; Significant; GE Healthcare. Other Research Support; Significant; TeraRecon. A.S. Kosinski: None. K.L. Lee: None. P.S. Douglas: Research Grant; Significant; Abiomed, Bristol-Myers Squibb, Gilead Sciences, Edwards Lifesciences, HeartFlow, Ikaria/Bellerophon, ResMed, Roche, Stealth Peptides. Other; Significant; UpToDate/Kluwer.
- © 2015 by American Heart Association, Inc.