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Wang C, Leng S, Tan RS, Chai P, Fam JM, Teo LLS, Chin CY, Ong CC, Baskaran L, Keng YJF, Low AFH, Chan MYY, Wong ASL, Chua SJT, Wu Q, Tan SY, Lim ST, Zhong L. Coronary CT Angiography-based Morphologic Index for Predicting Hemodynamically Significant Coronary Stenosis. Radiol Cardiothorac Imaging 2023; 5:e230064. [PMID: 38166346 DOI: 10.1148/ryct.230064] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024]
Abstract
Purpose To develop a new coronary CT angiography (CCTA)-based index, α×LL/MLD4, that considers lesion entrance angle (α) in addition to lesion length (LL) and minimal lumen diameter (MLD) and to evaluate its efficacy in predicting hemodynamically significant coronary stenosis compared with invasive coronary angiography (ICA)-derived fractional flow reserve (FFR). Materials and Methods This prospective study enrolled participants (September 2016-March 2020) from two centers who underwent CCTA followed by ICA (ClinicalTrials.gov identifier: NCT03054324). CCTA images were processed semiautomatically to measure LL, MLD, and α for calculating α×LL/MLD4. Diagnostic performance and accuracy of α×LL/MLD4 and LL/MLD4 in detecting hemodynamically significant coronary stenosis were compared against the reference standard (invasive FFR ≤ 0.80). Results In total, 133 participants (mean age, 63 years ± 9 [SD]; 99 [74%] men) with 210 stenosed coronary arteries were analyzed. Median α×LL/MLD4 was 54.0 degree/mm3 (IQR, 25.3-128.7) in participants with invasive FFR of 0.80 or less and 6.7 degree/mm3 (IQR, 3.3-12.8) in participants with invasive FFR of more than 0.80 (P < .001). The per-vessel accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for discriminating ischemic lesions were 86.2%, 83.1%, 88.4%, 84.1%, and 87.7% for α×LL/MLD4 and 80.5%, 66.3%, 90.9%, 84.3%, and 78.6% for LL/MLD4, respectively. Area under the receiver operating characteristic curve for discriminating hemodynamically significant stenosis was 0.93 for α×LL/MLD4, which was significantly greater than the values of 0.84 for LL/MLD4 and 0.63 for diameter stenosis (both P < .001). Conclusion The new morphologic index, α×LL/MLD4, incorporating lesion entrance angle achieved higher diagnostic performance in detecting hemodynamically significant lesions compared with diameter stenosis and LL/MLD4. Keywords: CT Angiography, Cardiac, Coronary Arteries, Ischemia, Infarction, Technology Assessment Clinical trial registration no. NCT03054324 Supplemental material is available for this article. © RSNA, 2023 See also the commentary by Fairbairn and Nørgaard in this issue.
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Affiliation(s)
- Chenxi Wang
- From the National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Dr, 169609 Singapore (C.W., S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); The Second Affiliated Hospital of Nanchang University, Nanchang, China (C.W., Q.W.); Duke-NUS Medical School, Singapore (S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); Department of Cardiology, National University Heart Centre, Singapore (P.C., A.F.H.L., M.Y.Y.C.); Yong Loo Lin School of Medicine (P.C., L.L.S.T., C.C.O., Y.J.F.K., A.F.H.L., M.Y.Y.C.) and Department of Biomedical Engineering (L.Z.), National University of Singapore, Singapore; and Department of Diagnostic Imaging, National University Hospital, Singapore (L.L.S.T., C.C.O.)
| | - Shuang Leng
- From the National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Dr, 169609 Singapore (C.W., S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); The Second Affiliated Hospital of Nanchang University, Nanchang, China (C.W., Q.W.); Duke-NUS Medical School, Singapore (S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); Department of Cardiology, National University Heart Centre, Singapore (P.C., A.F.H.L., M.Y.Y.C.); Yong Loo Lin School of Medicine (P.C., L.L.S.T., C.C.O., Y.J.F.K., A.F.H.L., M.Y.Y.C.) and Department of Biomedical Engineering (L.Z.), National University of Singapore, Singapore; and Department of Diagnostic Imaging, National University Hospital, Singapore (L.L.S.T., C.C.O.)
| | - Ru-San Tan
- From the National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Dr, 169609 Singapore (C.W., S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); The Second Affiliated Hospital of Nanchang University, Nanchang, China (C.W., Q.W.); Duke-NUS Medical School, Singapore (S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); Department of Cardiology, National University Heart Centre, Singapore (P.C., A.F.H.L., M.Y.Y.C.); Yong Loo Lin School of Medicine (P.C., L.L.S.T., C.C.O., Y.J.F.K., A.F.H.L., M.Y.Y.C.) and Department of Biomedical Engineering (L.Z.), National University of Singapore, Singapore; and Department of Diagnostic Imaging, National University Hospital, Singapore (L.L.S.T., C.C.O.)
| | - Ping Chai
- From the National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Dr, 169609 Singapore (C.W., S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); The Second Affiliated Hospital of Nanchang University, Nanchang, China (C.W., Q.W.); Duke-NUS Medical School, Singapore (S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); Department of Cardiology, National University Heart Centre, Singapore (P.C., A.F.H.L., M.Y.Y.C.); Yong Loo Lin School of Medicine (P.C., L.L.S.T., C.C.O., Y.J.F.K., A.F.H.L., M.Y.Y.C.) and Department of Biomedical Engineering (L.Z.), National University of Singapore, Singapore; and Department of Diagnostic Imaging, National University Hospital, Singapore (L.L.S.T., C.C.O.)
| | - Jiang Ming Fam
- From the National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Dr, 169609 Singapore (C.W., S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); The Second Affiliated Hospital of Nanchang University, Nanchang, China (C.W., Q.W.); Duke-NUS Medical School, Singapore (S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); Department of Cardiology, National University Heart Centre, Singapore (P.C., A.F.H.L., M.Y.Y.C.); Yong Loo Lin School of Medicine (P.C., L.L.S.T., C.C.O., Y.J.F.K., A.F.H.L., M.Y.Y.C.) and Department of Biomedical Engineering (L.Z.), National University of Singapore, Singapore; and Department of Diagnostic Imaging, National University Hospital, Singapore (L.L.S.T., C.C.O.)
| | - Lynette Li San Teo
- From the National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Dr, 169609 Singapore (C.W., S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); The Second Affiliated Hospital of Nanchang University, Nanchang, China (C.W., Q.W.); Duke-NUS Medical School, Singapore (S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); Department of Cardiology, National University Heart Centre, Singapore (P.C., A.F.H.L., M.Y.Y.C.); Yong Loo Lin School of Medicine (P.C., L.L.S.T., C.C.O., Y.J.F.K., A.F.H.L., M.Y.Y.C.) and Department of Biomedical Engineering (L.Z.), National University of Singapore, Singapore; and Department of Diagnostic Imaging, National University Hospital, Singapore (L.L.S.T., C.C.O.)
| | - Chee Yang Chin
- From the National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Dr, 169609 Singapore (C.W., S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); The Second Affiliated Hospital of Nanchang University, Nanchang, China (C.W., Q.W.); Duke-NUS Medical School, Singapore (S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); Department of Cardiology, National University Heart Centre, Singapore (P.C., A.F.H.L., M.Y.Y.C.); Yong Loo Lin School of Medicine (P.C., L.L.S.T., C.C.O., Y.J.F.K., A.F.H.L., M.Y.Y.C.) and Department of Biomedical Engineering (L.Z.), National University of Singapore, Singapore; and Department of Diagnostic Imaging, National University Hospital, Singapore (L.L.S.T., C.C.O.)
| | - Ching Ching Ong
- From the National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Dr, 169609 Singapore (C.W., S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); The Second Affiliated Hospital of Nanchang University, Nanchang, China (C.W., Q.W.); Duke-NUS Medical School, Singapore (S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); Department of Cardiology, National University Heart Centre, Singapore (P.C., A.F.H.L., M.Y.Y.C.); Yong Loo Lin School of Medicine (P.C., L.L.S.T., C.C.O., Y.J.F.K., A.F.H.L., M.Y.Y.C.) and Department of Biomedical Engineering (L.Z.), National University of Singapore, Singapore; and Department of Diagnostic Imaging, National University Hospital, Singapore (L.L.S.T., C.C.O.)
| | - Lohendran Baskaran
- From the National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Dr, 169609 Singapore (C.W., S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); The Second Affiliated Hospital of Nanchang University, Nanchang, China (C.W., Q.W.); Duke-NUS Medical School, Singapore (S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); Department of Cardiology, National University Heart Centre, Singapore (P.C., A.F.H.L., M.Y.Y.C.); Yong Loo Lin School of Medicine (P.C., L.L.S.T., C.C.O., Y.J.F.K., A.F.H.L., M.Y.Y.C.) and Department of Biomedical Engineering (L.Z.), National University of Singapore, Singapore; and Department of Diagnostic Imaging, National University Hospital, Singapore (L.L.S.T., C.C.O.)
| | - Yung Jih Felix Keng
- From the National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Dr, 169609 Singapore (C.W., S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); The Second Affiliated Hospital of Nanchang University, Nanchang, China (C.W., Q.W.); Duke-NUS Medical School, Singapore (S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); Department of Cardiology, National University Heart Centre, Singapore (P.C., A.F.H.L., M.Y.Y.C.); Yong Loo Lin School of Medicine (P.C., L.L.S.T., C.C.O., Y.J.F.K., A.F.H.L., M.Y.Y.C.) and Department of Biomedical Engineering (L.Z.), National University of Singapore, Singapore; and Department of Diagnostic Imaging, National University Hospital, Singapore (L.L.S.T., C.C.O.)
| | - Adrian Fatt Hoe Low
- From the National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Dr, 169609 Singapore (C.W., S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); The Second Affiliated Hospital of Nanchang University, Nanchang, China (C.W., Q.W.); Duke-NUS Medical School, Singapore (S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); Department of Cardiology, National University Heart Centre, Singapore (P.C., A.F.H.L., M.Y.Y.C.); Yong Loo Lin School of Medicine (P.C., L.L.S.T., C.C.O., Y.J.F.K., A.F.H.L., M.Y.Y.C.) and Department of Biomedical Engineering (L.Z.), National University of Singapore, Singapore; and Department of Diagnostic Imaging, National University Hospital, Singapore (L.L.S.T., C.C.O.)
| | - Mark Yan-Yee Chan
- From the National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Dr, 169609 Singapore (C.W., S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); The Second Affiliated Hospital of Nanchang University, Nanchang, China (C.W., Q.W.); Duke-NUS Medical School, Singapore (S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); Department of Cardiology, National University Heart Centre, Singapore (P.C., A.F.H.L., M.Y.Y.C.); Yong Loo Lin School of Medicine (P.C., L.L.S.T., C.C.O., Y.J.F.K., A.F.H.L., M.Y.Y.C.) and Department of Biomedical Engineering (L.Z.), National University of Singapore, Singapore; and Department of Diagnostic Imaging, National University Hospital, Singapore (L.L.S.T., C.C.O.)
| | - Aaron Sung Lung Wong
- From the National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Dr, 169609 Singapore (C.W., S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); The Second Affiliated Hospital of Nanchang University, Nanchang, China (C.W., Q.W.); Duke-NUS Medical School, Singapore (S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); Department of Cardiology, National University Heart Centre, Singapore (P.C., A.F.H.L., M.Y.Y.C.); Yong Loo Lin School of Medicine (P.C., L.L.S.T., C.C.O., Y.J.F.K., A.F.H.L., M.Y.Y.C.) and Department of Biomedical Engineering (L.Z.), National University of Singapore, Singapore; and Department of Diagnostic Imaging, National University Hospital, Singapore (L.L.S.T., C.C.O.)
| | - Siang Jin Terrance Chua
- From the National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Dr, 169609 Singapore (C.W., S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); The Second Affiliated Hospital of Nanchang University, Nanchang, China (C.W., Q.W.); Duke-NUS Medical School, Singapore (S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); Department of Cardiology, National University Heart Centre, Singapore (P.C., A.F.H.L., M.Y.Y.C.); Yong Loo Lin School of Medicine (P.C., L.L.S.T., C.C.O., Y.J.F.K., A.F.H.L., M.Y.Y.C.) and Department of Biomedical Engineering (L.Z.), National University of Singapore, Singapore; and Department of Diagnostic Imaging, National University Hospital, Singapore (L.L.S.T., C.C.O.)
| | - Qinghua Wu
- From the National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Dr, 169609 Singapore (C.W., S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); The Second Affiliated Hospital of Nanchang University, Nanchang, China (C.W., Q.W.); Duke-NUS Medical School, Singapore (S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); Department of Cardiology, National University Heart Centre, Singapore (P.C., A.F.H.L., M.Y.Y.C.); Yong Loo Lin School of Medicine (P.C., L.L.S.T., C.C.O., Y.J.F.K., A.F.H.L., M.Y.Y.C.) and Department of Biomedical Engineering (L.Z.), National University of Singapore, Singapore; and Department of Diagnostic Imaging, National University Hospital, Singapore (L.L.S.T., C.C.O.)
| | - Swee Yaw Tan
- From the National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Dr, 169609 Singapore (C.W., S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); The Second Affiliated Hospital of Nanchang University, Nanchang, China (C.W., Q.W.); Duke-NUS Medical School, Singapore (S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); Department of Cardiology, National University Heart Centre, Singapore (P.C., A.F.H.L., M.Y.Y.C.); Yong Loo Lin School of Medicine (P.C., L.L.S.T., C.C.O., Y.J.F.K., A.F.H.L., M.Y.Y.C.) and Department of Biomedical Engineering (L.Z.), National University of Singapore, Singapore; and Department of Diagnostic Imaging, National University Hospital, Singapore (L.L.S.T., C.C.O.)
| | - Soo Teik Lim
- From the National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Dr, 169609 Singapore (C.W., S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); The Second Affiliated Hospital of Nanchang University, Nanchang, China (C.W., Q.W.); Duke-NUS Medical School, Singapore (S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); Department of Cardiology, National University Heart Centre, Singapore (P.C., A.F.H.L., M.Y.Y.C.); Yong Loo Lin School of Medicine (P.C., L.L.S.T., C.C.O., Y.J.F.K., A.F.H.L., M.Y.Y.C.) and Department of Biomedical Engineering (L.Z.), National University of Singapore, Singapore; and Department of Diagnostic Imaging, National University Hospital, Singapore (L.L.S.T., C.C.O.)
| | - Liang Zhong
- From the National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Dr, 169609 Singapore (C.W., S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); The Second Affiliated Hospital of Nanchang University, Nanchang, China (C.W., Q.W.); Duke-NUS Medical School, Singapore (S.L., R.S.T., J.M.F., C.Y.C., L.B., Y.J.F.K., A.S.L.W., S.J.T.C., S.Y.T., S.T.L., L.Z.); Department of Cardiology, National University Heart Centre, Singapore (P.C., A.F.H.L., M.Y.Y.C.); Yong Loo Lin School of Medicine (P.C., L.L.S.T., C.C.O., Y.J.F.K., A.F.H.L., M.Y.Y.C.) and Department of Biomedical Engineering (L.Z.), National University of Singapore, Singapore; and Department of Diagnostic Imaging, National University Hospital, Singapore (L.L.S.T., C.C.O.)
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Udelson JE, Kelsey MD, Nanna MG, Fordyce CB, Yow E, Clare RM, Mark DB, Patel MR, Rogers C, 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, Chiswell K, Vemulapalli S, Douglas PS. Deferred Testing in Stable Outpatients With Suspected Coronary Artery Disease: A Prespecified Secondary Analysis of the PRECISE Randomized Clinical Trial. JAMA Cardiol 2023; 8:915-924. [PMID: 37610768 PMCID: PMC10448368 DOI: 10.1001/jamacardio.2023.2614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 06/26/2023] [Indexed: 08/24/2023]
Abstract
Importance Guidelines recommend deferral of testing for symptomatic people with suspected coronary artery disease (CAD) and low pretest probability. To our knowledge, no randomized trial has prospectively evaluated such a strategy. Objective To assess process of care and health outcomes in people identified as minimal risk for CAD when testing is deferred. Design, Setting, and Participants This randomized, pragmatic effectiveness trial included prespecified subgroup analysis of the PRECISE trial at 65 North American and European sites. Participants identified as minimal risk by the validated PROMISE minimal risk score (PMRS) were included. Intervention Randomization to a precision strategy using the PMRS to assign those with minimal risk to deferred testing and others to coronary computed tomography angiography with selective computed tomography-derived fractional flow reserve, or to usual testing (stress testing or catheterization with PMRS masked). Randomization was stratified by PMRS risk. Main Outcome Composite of all-cause death, nonfatal myocardial infarction (MI), or catheterization without obstructive CAD through 12 months. Results Among 2103 participants, 422 were identified as minimal risk (20%) and randomized to deferred testing (n = 214) or usual testing (n = 208). Mean age (SD) was 46 (8.6) years; 304 were women (72%). During follow-up, 138 of those randomized to deferred testing never had testing (64%), whereas 76 had a downstream test (36%) (at median [IQR] 48 [15-78] days) for worsening (30%), uncontrolled (10%), or new symptoms (6%), or changing clinician preference (19%) or participant preference (10%). Results were normal for 96% of these tests. The primary end point occurred in 2 deferred testing (0.9%) and 13 usual testing participants (6.3%) (hazard ratio, 0.15; 95% CI, 0.03-0.66; P = .01). No death or MI was observed in the deferred testing participants, while 1 noncardiovascular death and 1 MI occurred in the usual testing group. Two participants (0.9%) had catheterizations without obstructive CAD in the deferred testing group and 12 (5.8%) with usual testing (P = .02). At baseline, 70% of participants had frequent angina and there was similar reduction of frequent angina to less than 20% at 12 months in both groups. Conclusion and Relevance In symptomatic participants with suspected CAD, identification of minimal risk by the PMRS guided a strategy of initially deferred testing. The strategy was safe with no observed adverse outcome events, fewer catheterizations without obstructive CAD, and similar symptom relief compared with usual testing. Trial Registration ClinicalTrials.gov Identifier: NCT03702244.
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Affiliation(s)
- James E. Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Michelle D. Kelsey
- 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
| | - Christopher B. Fordyce
- Division of Cardiology, Department of Medicine, and Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Yow
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Robert M. Clare
- 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
| | | | - Nick Curzen
- Faculty of Medicine, University of Southampton and 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
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, and 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, and Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Victor Marinescu
- Midwest Cardiovascular Institute, Chicago Medical School, Edward-Elmhurst Health, Naperville, Illinois
- 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, and 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 and 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
- Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Karen Chiswell
- Duke Clinical Research Institute, 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
| | - Pamela S. Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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11
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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