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Douglas PS, Nanna MG, Kelsey MD, Yow E, Mark DB, Patel MR, Rogers C, Udelson JE, Fordyce CB, Curzen N, Pontone G, Maurovich-Horvat P, De Bruyne B, Greenwood JP, Marinescu V, Leipsic J, Stone GW, Ben-Yehuda O, Berry C, Hogan SE, Redfors B, Ali ZA, Byrne RA, Kramer CM, Yeh RW, Martinez B, Mullen S, Huey W, Anstrom KJ, Al-Khalidi HR, Vemulapalli S. Comparison of an Initial Risk-Based Testing Strategy vs Usual Testing in Stable Symptomatic Patients With Suspected Coronary Artery Disease: The PRECISE Randomized Clinical Trial. JAMA Cardiol 2023; 8:904-914. [PMID: 37610731 PMCID: PMC10448364 DOI: 10.1001/jamacardio.2023.2595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/26/2023] [Indexed: 08/24/2023]
Abstract
Importance Trials showing equivalent or better outcomes with initial evaluation using coronary computed tomography angiography (cCTA) compared with stress testing in patients with stable chest pain have informed guidelines but raise questions about overtesting and excess catheterization. Objective To test a modified initial cCTA strategy designed to improve clinical efficiency vs usual testing (UT). Design, Setting, and Participants This was a pragmatic randomized clinical trial enrolling participants from December 3, 2018, to May 18, 2021, with a median of 11.8 months of follow-up. Patients from 65 North American and European sites with stable symptoms of suspected coronary artery disease (CAD) and no prior testing were randomly assigned 1:1 to precision strategy (PS) or UT. Interventions PS incorporated the Prospective Multicenter Imaging Study for the Evaluation of Chest Pain (PROMISE) minimal risk score to quantitatively select minimal-risk participants for deferred testing, assigning all others to cCTA with selective CT-derived fractional flow reserve (FFR-CT). UT included site-selected stress testing or catheterization. Site clinicians determined subsequent care. Main Outcomes and Measures Outcomes were clinical efficiency (invasive catheterization without obstructive CAD) and safety (death or nonfatal myocardial infarction [MI]) combined into a composite primary end point. Secondary end points included safety components of the primary outcome and medication use. Results A total of 2103 participants (mean [SD] age, 58.4 [11.5] years; 1056 male [50.2%]) were included in the study, and 422 [20.1%] were classified as minimal risk. The primary end point occurred in 44 of 1057 participants (4.2%) in the PS group and in 118 of 1046 participants (11.3%) in the UT group (hazard ratio [HR], 0.35; 95% CI, 0.25-0.50). Clinical efficiency was higher with PS, with lower rates of catheterization without obstructive disease (27 [2.6%]) vs UT participants (107 [10.2%]; HR, 0.24; 95% CI, 0.16-0.36). The safety composite of death/MI was similar (HR, 1.52; 95% CI, 0.73-3.15). Death occurred in 5 individuals (0.5%) in the PS group vs 7 (0.7%) in the UT group (HR, 0.71; 95% CI, 0.23-2.23), and nonfatal MI occurred in 13 individuals (1.2%) in the PS group vs 5 (0.5%) in the UT group (HR, 2.65; 95% CI, 0.96-7.36). Use of lipid-lowering (450 of 900 [50.0%] vs 365 of 873 [41.8%]) and antiplatelet (321 of 900 [35.7%] vs 237 of 873 [27.1%]) medications at 1 year was higher in the PS group compared with the UT group (both P < .001). Conclusions and Relevance An initial diagnostic approach to stable chest pain starting with quantitative risk stratification and deferred testing for minimal-risk patients and cCTA with selective FFR-CT in all others increased clinical efficiency relative to UT at 1 year. Additional randomized clinical trials are needed to verify these findings, including safety. Trial Registration ClinicalTrials.gov Identifier: NCT03702244.
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Affiliation(s)
- Pamela S. Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Michael G. Nanna
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Michelle D. Kelsey
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Eric Yow
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Daniel B. Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Manesh R. Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | | | - James E. Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Christopher B. Fordyce
- Division of Cardiology, Department of Medicine, Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nick Curzen
- Faculty of Medicine, University of Southampton, Cardiothoracic Unit, University Hospital Southampton, Southampton, United Kingdom
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino Instituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, Onze Lieve Vrouwziekenhuis Clinic, Aalst, Belgium
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - John P. Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, United Kingdom
| | - Victor Marinescu
- Midwest Cardiovascular Institute, Chicago Medical School, Edward-Elmhurst Health, Naperville, Illinois
| | - Jonathon Leipsic
- Departments of Radiology and Medicine (Cardiology), University of British Columbia, Vancouver, British Columbia, Canada
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, United Kingdom
| | - Shea E. Hogan
- CPC Clinical Research, University of Colorado School of Medicine, Aurora
| | - Bjorn Redfors
- Cardiovascular Research Foundation, New York, New York
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ziad A. Ali
- St Francis Hospital & Heart Center, Roslyn, New York
| | - Robert A. Byrne
- Department of Cardiology, Cardiovascular Research Institute Dublin, Mater Private Network, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Beth Martinez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | | | | | - Hussein R. Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
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Nanna MG, Vemulapalli S, Fordyce CB, Mark DB, Patel MR, Al-Khalidi HR, Kelsey M, Martinez B, Yow E, Mullen S, Stone GW, Ben-Yehuda O, Udelson JE, Rogers C, Douglas PS. The prospective randomized trial of the optimal evaluation of cardiac symptoms and revascularization: Rationale and design of the PRECISE trial. Am Heart J 2022; 245:136-148. [PMID: 34953768 PMCID: PMC8979644 DOI: 10.1016/j.ahj.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 12/14/2021] [Accepted: 12/14/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Clinicians vary widely in their preferred diagnostic approach to patients with non-acute chest pain. Such variation exposes patients to potentially avoidable risks, as well as inefficient care with increased costs and unresolved patient concerns. METHODS The Prospective Randomized Trial of the Optimal Evaluation of Cardiac Symptoms and Revascularization (PRECISE) trial (NCT03702244) compares an investigational "precision" diagnostic strategy to a usual care diagnostic strategy in participants with stable chest pain and suspected coronary artery disease (CAD). RESULTS PRECISE randomized 2103 participants with stable chest pain and a clinical recommendation for testing for suspected CAD at 68 outpatient international sites. The investigational precision evaluation strategy started with a pre-test risk assessment using the PROMISE Minimal Risk Tool. Those at lowest risk were assigned to deferred testing (no immediate testing), and the remainder received coronary computed tomographic angiography (cCTA) with selective fractional flow reserve (FFRCT) for any stenosis meeting a threshold of ≥30% and <90%. For participants randomized to usual care, the clinical care team selected the initial noninvasive or invasive test (diagnostic angiography) according to customary practice. The use of cCTA as the initial diagnostic strategy was proscribed by protocol for the usual care strategy. The primary endpoint is time to a composite of major adverse cardiac events (MACE: all-cause death or non-fatal myocardial infarction) or invasive cardiac catheterization without obstructive CAD at 1 year. Secondary endpoints include health care costs and quality of life. CONCLUSIONS PRECISE will determine whether a precision approach comprising a strategically deployed combination of risk-based deferred testing and cCTA with selective FFRCT improves the clinical outcomes and efficiency of the diagnostic evaluation of stable chest pain over usual care.
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Affiliation(s)
- Michael G. Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | | | - Christopher B. Fordyce
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Daniel B. Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Manesh R. Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Michelle Kelsey
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Beth Martinez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Eric Yow
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Gregg W. Stone
- Icahn School of Medicine at Mount Sinai, Mount Sinai Heart and the Cardiovascular Research Foundation, New York, NY
| | - Ori Ben-Yehuda
- Cardiovascular Research Foundation, NY, NY and the University of California, San Diego
| | - James E. Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA
| | | | - Pamela S. Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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