Identification of Patients With Stable Chest Pain Deriving Minimal Value From Noninvasive Testing

Fordyce, Christopher B.; Douglas, Pamela S.; Roberts, Rhonda; Hoffmann, Udo; Al‐Khalidi, Hussein R.; Patel, Manesh R.; Granger, Christopher B.; Kostis, John B.; Mark, Daniel B.; Lee, Kerry L.; Udelson, James E.

doi:10.1001/jamacardio.2016.5501

Cited by 84 publications

(71 citation statements)

References 22 publications

(26 reference statements)

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“…In both trials, the use of a symptom-focused strategy endorsed by NICE, in contrast with a Bayesian–risk based approach endorsed by ACC/AHA and ESC, resulted in a 3- to 4-fold increase in the number of patients for whom no further investigation for the presence of CAD is recommended. This is reassuring given concerns raised recently that the updated NICE guidance would lead to an increase in indiscriminate diagnostic testing (19) , as well as strategies being considered to defer testing in those patients with very low risk 20 , 21 . Furthermore, the group designated by NICE for no testing (nonanginal symptoms) demonstrated <10% prevalence of coronary obstruction across both trial cohorts, below the threshold adjudged to reflect low risk in both the ACC/AHA and ESC guidelines.…”

Section: Discussionmentioning

confidence: 90%

Comparison of International Guidelines for Assessment of Suspected Stable Angina

Adamson

Newby

Hill

et al. 2018

JACC: Cardiovascular Imaging

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ObjectivesThis study sought to compare the performance of major guidelines for the assessment of stable chest pain including risk-based (American College of Cardiology/American Heart Association and European Society of Cardiology) and symptom-focused (National Institute for Health and Care Excellence) strategies.BackgroundAlthough noninvasive testing is not recommended in low-risk individuals with stable chest pain, guidelines recommend differing approaches to defining low-risk patients.MethodsPatient-level data were obtained from the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) and SCOT-HEART (Scottish Computed Tomography of the Heart) trials. Pre-test probability was determined and patients dichotomized into low-risk and intermediate-high–risk groups according to each guideline’s definitions. The primary endpoint was obstructive coronary artery disease on coronary computed tomography angiography. Secondary endpoints were coronary revascularization at 90 days and cardiovascular death or nonfatal myocardial infarction up to 3 years.ResultsIn total, 13,773 patients were included of whom 6,160 had coronary computed tomography angiography. The proportions of patients identified as low risk by the American College of Cardiology/American Heart Association, European Society of Cardiology, and National Institute for Health and Care Excellence guidelines, respectively, were 2.5%, 2.5%, and 10.0% within PROMISE, and 14.0%, 19.8%, and 38.4% within SCOT-HEART. All guidelines identified lower rates of obstructive coronary artery disease in low- versus intermediate-high–risk patients with a negative predictive value of ≥0.90. Compared with low-risk groups, all intermediate-high–risk groups had greater risks of coronary revascularization (odds ratio [OR]: 2.2 to 24.1) and clinical outcomes (OR: 1.84 to 5.8).ConclusionsCompared with risk-based guidelines, symptom-focused assessment identifies a larger group of low-risk chest pain patients potentially deriving limited benefit from noninvasive testing. (Scottish Computed Tomography of the Heart Trial [SCOT-HEART]; NCT01149590; Prospective Multicenter Imaging Study for Evaluation of Chest Pain [PROMISE]; NCT01174550)

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Section: Discussionmentioning

confidence: 90%

Comparison of International Guidelines for Assessment of Suspected Stable Angina

Adamson

Newby

Hill

et al. 2018

JACC: Cardiovascular Imaging

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“…The newly developed PROMISE (Prospective Multicenter Imaging Study of Chest Pain) minimal risk tool was designed to identify “low‐risk” patients in whom deferred noninvasive testing (noninvasive coronary angiography or functional stress testing) may be considered 56. Subjects with minimal risk had a low‐risk profile (0.5% risk of cardiovascular death and MI at a median 25 months).…”

Section: Obstructive Cad Likelihood Scoresmentioning

confidence: 99%

“…Comparison of primary, secondary prevention risk versus observed risk in an example of stable INOCA patient is presented in Figure 2 40, 47, 56, 63, 65, 66, 67, 68, 69, 70, 71. The primary prevention scores, developed in asymptomatic populations, predicted that risks vary between 1% and ≈5% and underestimate the observed INOCA risk.…”

Section: Primary and Secondary Prevention Risk Versus Observed Inoca mentioning

confidence: 99%

Ischemia and No Obstructive Coronary Artery Disease (INOCA): What Is the Risk?

Herscovici

Sedlak

Wei

et al. 2018

JAHA

139

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“… 39 We have also reported that absence of hypertension, dyslipidaemia and tobacco use are associated with a lower rate of adverse cardiovascular events. 40 We also found that treatment gaps among patients with hypertension or diabetes were not associated with an increased risk of adverse cardiovascular events. In contrast, treatment gaps among patients with dyslipidaemia were associated with an increased risk of adverse cardiovascular events.…”

Section: Discussionmentioning

confidence: 59%

Quantifying sociodemographic and income disparities in medical therapy and lifestyle among symptomatic patients with suspected coronary artery disease: a cross-sectional study in North America

et al. 2017

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ObjectivesTo evaluate potential gaps in preventive medical therapy and healthy lifestyle practices among symptomatic patients with suspected coronary artery disease (CAD) seeing primary care physicians and cardiologists and how gaps vary by sociodemographic characteristics and baseline cardiovascular risk.DesignCross-sectional study assessing potential preventive gaps.Participants10 003 symptomatic outpatients evaluated by primary care physicians, cardiologists or other specialists for suspected CAD.SettingPROspective Multicenter Imaging Study for Evaluation of Chest Painfrom 2010 to 2014.MeasuresPrimary measures were absence of an antihypertensive, statin or angiotensin-converting enzyme inhibitor/angiotensin receptor blocker for renal protection in patients with hypertension, dyslipidaemia or diabetes, respectively, and being sedentary, smoking or being obese.ResultsPreventive treatment gaps affected 14% of patients with hypertension, 36% of patients with dyslipidaemia and 32% of patients with diabetes. Overall, 49% of patients were sedentary, 18% currently smoked and 48% were obese. Women were significantly more likely to not take a statin for dyslipidaemia and to be sedentary. Patients with lower socioeconomic status were also significantly more likely to not take a statin. Compared with Whites, Blacks were significantly more likely to be obese, while Asians were less likely to smoke or be obese. High-risk patients sometimes experienced larger preventive care gaps than low-risk patients. For patients with dyslipidaemia, the presence of a treatment gap was associated with a higher risk of an adverse event (HR 1.35, 95% CI 1.02 to 1.82).ConclusionsAmong contemporary, symptomatic patients with suspected CAD, significant gaps exist in preventive care and lifestyle practices, and high-risk patients sometimes had larger gaps. Differences by sex, age, race/ethnicity, socioeconomic status and geography are modest but contribute to disparities and have implications for improving opulation health. For patients with dyslipidaemia, the presence of a treatment gap was associated with a higher risk of an adverse event.Clinical trial registrationClinical Trials.gov identifier NCT01174550.

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Identification of Patients With Stable Chest Pain Deriving Minimal Value From Noninvasive Testing

Abstract: clinicaltrials.gov Identifier: NCT01174550.

Cited by 84 publications

References 22 publications

Comparison of International Guidelines for Assessment of Suspected Stable Angina

Comparison of International Guidelines for Assessment of Suspected Stable Angina

Ischemia and No Obstructive Coronary Artery Disease (INOCA): What Is the Risk?

Quantifying sociodemographic and income disparities in medical therapy and lifestyle among symptomatic patients with suspected coronary artery disease: a cross-sectional study in North America

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