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Updated: Nov 9, 2025
Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function
Published on: March 15, 2022
Survival After Initial Stress Testing vs Anatomic Testing in Suspected Coronary Artery Disease: Long-Term Follow-Up
Pamela S Douglas1,2, Amanda Stebbins1, Borek Foldyna3
1Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
Insights
Choosing between coronary computed tomographic angiography (CTA) and stress testing for suspected coronary artery disease (CAD) did not impact long-term mortality. Both diagnostic approaches showed similar outcomes in patients over a decade.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Clinical Trials
Background:
- Coronary artery disease (CAD) diagnosis often relies on noninvasive testing.
- The PROMISE trial initially compared functional (stress) versus anatomic (coronary computed tomographic angiography [CTA]) testing for symptomatic patients.
Purpose of the Study:
- To determine long-term mortality outcomes in patients randomized to initial CTA or stress testing for suspected CAD.
- To evaluate the prognostic significance of different test results on mortality.
Main Methods:
- A 2025 follow-up analysis of the PROMISE randomized clinical trial (2009-2014) using the National Death Index.
- 10,003 symptomatic patients were randomized to initial CTA or stress testing.
- Median follow-up was 10.6 years, with all-cause death as the primary endpoint.
Main Results:
- No significant difference in all-cause mortality between CTA and stress testing arms (14.4% vs. 14.5%).
- Cardiovascular mortality also showed no demonstrable difference, with a point estimate favoring CTA.
- Abnormal CTA findings (mild, moderate, severe) significantly elevated adjusted HRs for death, while only severe stress test abnormalities were prognostically significant.
Conclusions:
- Initial noninvasive test selection (CTA vs. stress testing) did not affect 10-year all-cause or cardiovascular mortality in patients with suspected CAD.
- CTA findings indicating any degree of coronary artery disease conferred elevated mortality risk.
- The choice of initial noninvasive testing strategy does not appear to influence long-term survival in this patient population.
Importance:
Symptoms suggestive of coronary artery disease (CAD) often require noninvasive testing for diagnostic and prognostic evaluation.
Objective:
To determine long-term outcomes in patients randomized to functional (stress) vs anatomic (coronary computed tomographic angiography [CTA]) initial testing.
Design, Setting, And Participants:
This study is a 2025 follow-up analysis of mortality of participants in the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) randomized clinical trial, which was conducted from 2009 to 2014, using a 2024 National Death Index search. Median (IQR) follow-up duration was 10.6 (9.9-11.3) years; maximum follow-up was 12.4 years. PROMISE was conducted at 193 multispecialty outpatient sites in North America among 10 003 symptomatic patients requiring testing for suspected CAD. Data analysis was conducted from August 2024 to March 2025.
Intervention:
Participants were randomized 1:1 to initial CTA or stress testing. Testing and subsequent care were performed by sites according to usual practices.
Main Outcomes And Measures:
The PROMISE trial's original primary end point was death, myocardial infarction, unstable angina hospitalization, or major procedural complication. The primary end point for extended follow-up was all-cause death, with cardiovascular (CV) death as a secondary end point.
Results:
At enrollment, mean (SD) participant age was 61 (8) years, 5270 participants (52.7%) were women, and 8762 (87.6%) had chest pain or dyspnea. Death occurred in 1128 participants (14.4%), including 558 (14.3%) in the CTA arm and 570 (14.5%) in the stress arm (unadjusted hazard ratio [HR], 0.98; 95% CI, 0.87-1.10). There was no demonstrable difference in cardiovascular mortality, although the point estimate favored CTA (HR, 0.84; 95% CI, 0.67-1.05; adjusted HR, 0.89; 95% CI, 0.41-1.94). There were no significant interactions between all-cause death or CV death and study arm by age (<60 or ≥60 years) (P value for interaction = .19), gender (P value for interaction = .60), or race and ethnicity (P value for interaction = .47). A CTA indicating any degree of abnormality, including mild (nonobstructive CAD), moderate, and severe findings, conferred elevated adjusted HRs of death (1.99-3.44; all P < .001) compared to normal study results. Among stress testing results, only a severe abnormality was prognostically significant (HR, 1.45; 95% CI, 1.10-1.91). In landmark analyses of those alive at 90 days, there were no interactions between randomized testing and use of statins (P value for interaction = .22), β-blockers (P value for interaction = .76), or antiplatelet agents (P value for interaction = .49).
Conclusions And Relevance:
In long-term follow-up of the PROMISE randomized clinical trial, initial noninvasive test selection in patients with stable symptoms of suspected CAD did not affect all-cause or CV mortality at 10 years.
Trial Registration:
ClinicalTrials.gov Identifier: NCT01174550.
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01:26Exercise Stress Test
Exercise stress testing, commonly known as a treadmill test, is a noninvasive procedure used to evaluate cardiovascular function and diagnose heart conditions.
Definition
An exercise stress test measures the heart's response to exertion using a treadmill or stationary bicycle. Chest electrodes record the heart's electrical activity through an ECG, and blood pressure is monitored regularly.
Purposes