New Promises for Refining Risk Stratification From Anatomical and Functional Assessment of Stable Chest Pain
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Article, see p 2320
The evaluation of patients presenting with stable but suspected coronary artery disease (CAD) is by far one of the most common diagnostic evaluation strategies undertaken within cardiovascular medicine. The 2 most prominent indications for testing supported by substantive clinical evidence include diagnosis of obstructive CAD and risk stratification. The evidence supporting prognostication based on diagnostic test findings in the patient with stable ischemic heart disease is abundant, with thousands of reports noting near-term prediction of major adverse events for all noninvasive procedures including anatomic imaging, with coronary computed tomographic angiography (CTA), and stress testing (ie, stress nuclear or echocardiography or exercise electrocardiography). Observational evidence for each modality supports that, in general, risk increases in a graded manner with the extent and severity of abnormalities on functional stress testing or with anatomic CAD.
This proportional relationship between the extent and severity of abnormalities and risk is the basis for therapeutic intervention whereby hazard drives the intensity of comprehensive management.1 Conceptually, those with the most severe functional test abnormalities or those with obstructive CAD generally receive symptom-guided anti-ischemic therapy and aggressive risk factor modification. Conversely, low-risk patients have few major CAD events and less prevalent CAD, and thereby should rarely warrant angiography to identify ischemia-associated lesions. But, if present, modifiable risk factors would normally still be addressed. This is the accepted standard approach to apply risk estimates into clinical management of patients with stable ischemic heart disease. There may, however, be profound differences, as perceived by the patient or the physician, in the need for therapy targeting modifiable risk factors when either functional or anatomic tests yield normal or intermediate results.
In this issue of Circulation, Hoffmann and colleagues report on the effectiveness of risk …