Achieving the Full “PROMISE” of Imaging Outcomes Research
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Like many areas in cardiology, ongoing imaging technology development creates a need for high-quality data on how best to incorporate potential game changers such as coronary computed tomographic angiography (CTA) into clinical care. In 2015, several large, outcomes-based, randomized trials compared the use of CTA with stress testing for the diagnosis of stable chest pain, including the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain; NCT01174550), SCOT-HEART (Scottish Computed Tomography of the Heart; NCT01149590), and PLATFORM (Prospective Longitudinal Trial of FFRCT Outcome and Resource Impacts; clinical outcomes of FFRCT-guided diagnostic strategies versus usual care trial; NCT01943903) trials.1–3 Although each of these studies provides evidence that CTA improves diagnostic thinking and catheterization laboratory referral decisions, clinical event rates with CTA and usual care strategies were similar. As a result, although many observers view these trials as establishing new evidence-based testing options, others find them to be insufficiently compelling to change clinical care. This debate aside, digging more deeply into these trials uncovers a great deal of important and novel information about patients with stable chest pain and suspected coronary artery disease, applicable to both clinical care and future research. These data are particularly important given the large size of this population and the dearth of contemporary studies of patients undergoing elective testing for suspected coronary artery disease (CAD).
Although all 3 trial cohorts were symptomatic and had a high risk factor burden, they had low cardiovascular event rates, just 1% to 2% per year. This low event rate has prompted some observers to suggest that a strategy of …