Clinical risk prediction, coronary computed tomography angiography, and cardiovascular events in new-onset chest pain: The PROMISE and SCOT-HEART trials

TY - JOUR

T1 - Clinical risk prediction, coronary computed tomography angiography, and cardiovascular events in new-onset chest pain

T2 - The PROMISE and SCOT-HEART trials

AU - Rasmussen, Laust Dupont

AU - Schmidt, Samuel Emil

AU - Knuuti, Juhani

AU - Vrints, Christiaan

AU - Bøttcher, Morten

AU - Foldyna, Borek

AU - Williams, Michelle C.

AU - Newby, David E.

AU - Douglas, Pamela S.

AU - Winther, Simon

N1 - Publisher Copyright: © 2024 The Author(s). Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved.

PY - 2025/2/1

Y1 - 2025/2/1

N2 - Background and Aims: Whether index testing using coronary computed tomography angiography (CTA) improves outcomes in stable chest pain is debated. The risk factor weighted clinical likelihood (RF-CL) model provides likelihood estimation of obstructive coronary artery disease. This study investigated the prognostic effect of coronary CTA vs. usual care by RF-CL estimates. Methods: Large-scale studies randomized patients (N = 13 748) with stable chest pain to coronary CTA as part of the initial work-up in addition to or instead of usual care including functional testing. Patients were stratified according to RF-CL estimates [RF-CL: very-low (≤5%), low (>5%-15%), and moderate/high (>15%)]. The primary endpoint was myocardial infarction or death at 3 years. Results: The primary endpoint occurred in 313 (2.3%) patients. Event rates were similar in patients allocated to coronary CTA vs. usual care [risk difference (RD) 0.3%, hazard ratio (HR) 0.84 (95% CI 0.67-1.05)]. Overall, 33%, 44%, and 23% patients had very-low, low, and moderate/high RF-CL. Risk was similar in patients with very low and moderate/high RF-CL allocated to coronary CTA vs. usual care [very low: RD 0.3%, HR 1.27 (0.74-2.16); moderate/high: RD 0.5%, HR 0.88 (0.63-1.23)]. Conversely, patients with low RF-CL undergoing coronary CTA had lower event rates [RD 0.7%, HR 0.67 (95% CI 0.47-0.97)]. The number needed to test using coronary CTA to prevent one event within 3 years was 143. Conclusions: Despite an overall good prognosis, low RF-CL patients have reduced risk of myocardial infarction or death when allocated to coronary CTA vs. usual care. Risk is similar in patients with very-low and moderate/high likelihood.

AB - Background and Aims: Whether index testing using coronary computed tomography angiography (CTA) improves outcomes in stable chest pain is debated. The risk factor weighted clinical likelihood (RF-CL) model provides likelihood estimation of obstructive coronary artery disease. This study investigated the prognostic effect of coronary CTA vs. usual care by RF-CL estimates. Methods: Large-scale studies randomized patients (N = 13 748) with stable chest pain to coronary CTA as part of the initial work-up in addition to or instead of usual care including functional testing. Patients were stratified according to RF-CL estimates [RF-CL: very-low (≤5%), low (>5%-15%), and moderate/high (>15%)]. The primary endpoint was myocardial infarction or death at 3 years. Results: The primary endpoint occurred in 313 (2.3%) patients. Event rates were similar in patients allocated to coronary CTA vs. usual care [risk difference (RD) 0.3%, hazard ratio (HR) 0.84 (95% CI 0.67-1.05)]. Overall, 33%, 44%, and 23% patients had very-low, low, and moderate/high RF-CL. Risk was similar in patients with very low and moderate/high RF-CL allocated to coronary CTA vs. usual care [very low: RD 0.3%, HR 1.27 (0.74-2.16); moderate/high: RD 0.5%, HR 0.88 (0.63-1.23)]. Conversely, patients with low RF-CL undergoing coronary CTA had lower event rates [RD 0.7%, HR 0.67 (95% CI 0.47-0.97)]. The number needed to test using coronary CTA to prevent one event within 3 years was 143. Conclusions: Despite an overall good prognosis, low RF-CL patients have reduced risk of myocardial infarction or death when allocated to coronary CTA vs. usual care. Risk is similar in patients with very-low and moderate/high likelihood.

KW - Chronic coronary syndrome

KW - Clinical likelihood

KW - Coronary computed tomography angiography

KW - Pre-test probability

UR - https://www.scopus.com/pages/publications/85214515628

U2 - 10.1093/eurheartj/ehae742

DO - 10.1093/eurheartj/ehae742

M3 - Journal article

C2 - 39453783

AN - SCOPUS:85214515628

SN - 0195-668X

VL - 46

SP - 473

EP - 483

JO - European Heart Journal

JF - European Heart Journal

IS - 5

ER -