New risk analysis strategy benefits patients with chest pain compared to standard testing approach

New risk analysis strategy benefits patients with chest pain compared to standard testing approach

A study comparing two approaches to diagnosing heart disease found that a risk assessment strategy was superior to the usual approach of immediately performing functional tests or catheterizations in low- to intermediate-risk patients with new-onset chest pain.

The study, presented Nov. 6 at the American Heart Association's 2022 Scientific Sessions, supports a risk assessment strategy that either postpones testing in low-risk patients or uses coronary computed tomography angiography (CTA), a CT scan with a contrast agent, to evaluate for blockages.

The risk analysis approach has been outlined in guidelines and is advocated as a means of reducing often unnecessary and costly testing. However, it has never been rigorously tested in a randomized trial, and its clinical use has lagged without definitive proof of its effectiveness compared to various functional stress tests.

“New-onset chest pain is a common clinical problem that involves a lot of testing, work and expense,” said study leader Pamela S. Douglas, MD, a member of the Duke Clinical Research Institute and Ursula Geller Professor of Research in Cardiovascular Diseases at Duke University School of Medicine.

“Our study provides evidence that testing in low-risk patients is likely to be negative for coronary artery disease and patients will continue to do well,” Douglas said. “As a result, we should postpone testing for these low-risk individuals.”

Douglas and colleagues enrolled more than 2,100 patients in the United States and Europe with new-onset chest pain in the PRECISE clinical trial.The average age of the participants was 58 years, with about an equal number of men and women.

Half of the patients were randomly assigned to receive standard tests—including stress echocardiogram, nuclear stress test, stress MRI or catheterization—that doctors chose at their own discretion.

The other half of the participants were randomized to the precision strategy, which used a

Pre-test probabilistic assessment to guide next steps, including delayed testing or CTA, with selective use of image analysis software to determine the significance of blockages.

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In both groups, approximately 21% of symptomatic patients were assessed as having a low risk of heart disease. Of these low-risk patients in the usual testing group, 86% underwent some type of testing, compared to 37% in the precision strategy group.

The primary focus was whether there were differences between the two diagnostic approaches within one year for any combination of the following outcomes: death from any cause, nonfatal myocardial infarction, or catheterizations that did not show blockages and may have been unnecessary.

The researchers found that the precision strategy significantly reduced the occurrence of the compound endpoint compared to the usual stress testing approaches.

To provide a complete picture of clinical value, investigators balanced this demonstrated effectiveness with an investigation into any safety concerns. There were no differences in death or the combination of death and myocardial infarction, but there was a small, nonsignificant difference in nonfatal myocardial infarction in the precision group.

In stable, symptomatic patients with suspected heart disease who doctors believe need testing, a precision strategy Incorporating a range of measures based on guideline recommendations will improve outcomes compared to traditional testing.

Pamela S. Douglas, MD, member of the Duke Clinical Research Institute and Ursula Geller Professor of Research in Cardiovascular Diseases, Duke University School of Medicine

In addition to Douglas, study authors include Michael G. Nanna, Michelle D. Kelsey, Eric Yow, Daniel B. Mark, Manesh R. Patel, Campbell Rogers, James E. Udelson, Christopher B. Fordyce, Nick Curzen, Gianluca Pontone, Pál Maurovich-Horvat, Bernard De Bruyne, John P. Greenwood, Victor Marinescu, Jonathon Leipsic, Gregg W. Stone, Ori Ben-Yehuda, Colin Berry, Shea E. Hogan, Bjorn Redfors, Ziad A. Ali, Robert A. Byrne, Christopher M. Kramer, Robert W. Yeh, Beth Martinez, Sarah Mullen, Whitney Huey, Kevin J. Anstrom, Hussein R. Al-Khalidi and Sreekanth Vemulapalli, for the PRECISE Investigators/

The study was funded by HeartFlow, a medical technology company.

Source:

Duke Health

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