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Estimating the real-world performance of the PROMISE minimal-risk tool
M G Nanna1, T Y Wang1, K Chiswell1
1Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
Insights
The PROMISE Minimal-Risk Tool identifies low-risk patients with stable chest pain, showing they have less obstructive coronary artery disease (CAD) and better survival, suggesting potential for non-invasive management.
Area of Science:
- Cardiology
- Clinical Risk Stratification
- Preventive Cardiology
Background:
- Stable chest pain is a frequent reason for cardiac catheterization.
- The Prospective Multicenter Imaging Study for Evaluation (PROMISE) Minimal-Risk Tool was evaluated for its prognostic value.
- Identification of very low-risk patients for obstructive coronary artery disease (CAD) and adverse cardiovascular outcomes is crucial.
Purpose of the Study:
- To assess the prognostic utility of the PROMISE Minimal-Risk Tool in patients with stable angina undergoing elective cardiac catheterization.
- To identify patients at very low risk of obstructive CAD and downstream cardiovascular events.
- To compare outcomes between low-risk and non-low-risk groups defined by the PROMISE tool.
Main Methods:
- The PROMISE Minimal-Risk Tool was applied to 6251 patients with stable angina without known CAD.
- Patients with scores >0.46 were classified as low-risk.
- Logistic regression was used to compare the likelihood of freedom from obstructive CAD, 2-year survival, and 2-year survival free of myocardial infarction (MI) or MI/revascularization between groups.
Main Results:
- 17.3% of patients were classified as low-risk.
- Low-risk patients had a lower prevalence of obstructive CAD (14.9%) and significantly higher 2-year survival (98.2% vs. 94.4%) compared to non-low-risk patients.
- Low-risk patients also demonstrated significantly better MI-free survival (97.2% vs. 91.9%) and MI/revascularization-free survival (86.2% vs. 59.9%).
Conclusions:
- The PROMISE Minimal-Risk Tool effectively identifies a subgroup of stable chest pain patients (17%) with low obstructive CAD prevalence and favorable survival.
- These findings suggest that low-risk patients may not benefit from cardiac catheterization.
- Further research is warranted to confirm the benefits of medical management alone in this low-risk population.
Background:
Stable chest pain is a common indication for cardiac catheterization. We assessed the prognostic value of the Prospective Multicenter Imaging Study for Evaluation (PROMISE) Minimal-Risk Tool in identifying patients who are at very low risk of obstructive coronary artery disease (CAD) or downstream cardiovascular adverse outcomes.
Methods:
We applied the PROMISE Minimal-Risk Tool to consecutive patients without known CAD who underwent elective cardiac catheterization for stable angina from January 1, 2000 to December 31, 2014 in the Duke Databank for Cardiovascular Disease (DDCD). Patients with scores >0.46 (top decile of lowest-risk from the PROMISE cohort) were classified as low-risk. Logistic regression modeling compared likelihood of freedom from obstructive coronary artery disease on index angiography, 2-year survival, and 2-year survival free of myocardial infarction (MI) and MI/revascularization between low- and non low-risk patients. Alternative cut points to define low- risk patients were also explored.
Results:
Among 6251 patients undergoing cardiac catheterization for stable chest pain, 1082 (17.3%) were low-risk per the PROMISE minimal-risk tool. Among low risk patients, obstructive coronary artery disease was observed in 14.9% and left main disease (≥ 50% Stenosis) was rare (0.9%). Compared with other patients, low risk patients had a higher likelihood of freedom from obstructive coronary disease on index catheterization (85.1% vs. 44.2%, OR 4.84, 95% CI 4.06-5.77). Low risk patients had significantly higher survival (98.2% vs. 94.4%, OR 3.18, 95% CI 1.99-5.08), MI-free survival (97.2% vs. 91.9%, OR 3.03, 95% CI 2.07-4.45), and MI/revascularization-free survival (86.2 vs. 59.9%, OR 4.19, 95% CI 3.48-5.05) at 2 years than non-low risk patients. Operating characteristics for predicting the outcomes of interest varied modestly depending on the low-risk cut-point used but the positive predictive value for 2 year freedom from death was >98% regardless.
Conclusion:
The PROMISE minimal-risk tool identifies 17% of stable chest pain patients referred to cardiac catheterization as low risk. These patients have a low prevalence of obstructive CAD and better survival than non-low risk patients. While this suggests that these patients are unlikely to benefit from catheterization, further research is needed to confirm a favorable downstream prognosis with medical management alone.
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