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The PROMISE Minimal Risk Score Improves Risk Classification of Symptomatic Patients With Suspected CAD
Laust D Rasmussen1, Christopher B Fordyce2, Louise Nissen3
1Department of Cardiology, Gødstrup Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
Insights
The PROMISE minimal risk score (PMRS) helps identify patients with low risk for coronary artery disease (CAD). This score can reduce unnecessary diagnostic testing for individuals with intermediate pretest probability (PTP) of obstructive CAD.
Area of Science:
- Cardiology
- Medical Diagnostics
- Risk Stratification
Background:
- Current guidelines lack clear diagnostic testing recommendations for patients with 5-15% pretest probability (PTP) of obstructive coronary artery disease (CAD).
- The diagnostic and prognostic value of the PROMISE minimal risk score (PMRS) in this patient group remains unclear.
Purpose of the Study:
- To enhance the evaluation of stable patients with suspected CAD.
- To identify patients at minimal risk of CAD and adverse events using the PMRS in individuals with >5% to 15% PTP of obstructive CAD.
Main Methods:
- Utilized data from the PROMISE and Dan-NICAD trials for patients with >5% to 15% PTP.
- Determined the PMRS cutoff for ≤5% obstructive CAD prevalence in a PROMISE cohort.
- Validated the PMRS cutoff for obstructive CAD in the Dan-NICAD cohort and for prognostic impact in the PROMISE cohort.
Main Results:
- A PMRS of ≥34% identified patients with ≤5% CAD prevalence in the discovery cohort.
- This cutoff reclassified 31.9% of patients in the validation cohort to a low-risk group (3.2% obstructive CAD).
- A PMRS ≥34% showed a trend towards lower risk of myocardial infarction and death.
Conclusions:
- Combining traditional PTP with PMRS effectively reclassifies one-third of intermediate-risk patients to a very low-risk group.
- This strategy may improve risk stratification for suspected CAD.
- The approach has the potential to reduce unnecessary diagnostic testing.
Background:
Guidelines for evaluating patients with suspected coronary artery disease (CAD) recommend pretest probability (PTP) estimation but provide no clear recommendations regarding diagnostic testing in patients with >5% to 15% risk of obstructive CAD. The diagnostic and prognostic value of PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) minimal risk score (PMRS) calculation in this patient group is unknown.
Objectives:
This work aims to improve the evaluation of stable patients with suspected CAD by using the PMRS, which identifies patients at minimal risk of CAD and events in patients with >5% to 15% PTP of obstructive CAD.
Methods:
Greater than 5% to 15% PTP patients from 2 large clinical trials were used for subcohort derivation: PROMISE (N = 10,003) and Dan-NICAD (Danish study of Non-Invasive Testing in Coronary Artery Disease) (N = 3,252). First, the PMRS cutoff associated with a prevalence of obstructive CAD ≤5% was determined in the >5% to 15% PTP PROMISE core lab computed tomographic angiography patients (discovery cohort: n = 2,191). This cutoff was validated for obstructive CAD in >5% to 15% PTP Dan-NICAD patients (CAD validation cohort: n = 1,386) and for prognostic impact on death and myocardial infarction in >5% to 15% PTP PROMISE non-core lab computed tomographic angiography patients (prognosis validation cohort: n = 2,753).
Results:
In the discovery cohort, a CAD prevalence of ≤5% was found at a PMRS of ≥34%. In the CAD validation cohort, this cutoff down-classified 442 (31.9%) of >5% to 15% PTP patients into the low PTP group (CAD ≤5%); the prevalence of obstructive CAD in down-classified patients was 3.2% compared to 7.1% in non-down-classified patients. A PMRS ≥34% was nonsignificantly associated with a lower risk of myocardial infarction and death in the prognosis validation cohort (HR: 0.58 [95% CI: 0.29-1.18]; P = 0.13).
Conclusions:
For evaluating patients with suspected CAD, a combined use of traditional PTP and the PMRS correctly down-classified one-third of >5% to 15% PTP patients into a group with very low prevalence of obstructive CAD and adverse events. The proposed strategy may improve risk stratification and help reduce unneeded diagnostic testing.
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