PROMISEs, Promises: Stress Test or CT Angio for Patients With Stable Chest Pain

I posted the following comments for SERMO, a social network for over 300,000 physicians yesterday.. I would encourage any physician readers to join SERMO and engage in the medical discussions going on there.

As physicians, we have to decide on a daily basis how to evaluate the patient who has chest pain. Most chest pain is not cardiac, but if we miss the patient whose chest pain is a sign of coronary ischemia or impending infarct, the results can be catastrophic.
The standard approach across the US for patients presenting with stable chest pain is to do some sort of stress test. Usually, treadmill or chemical ECG stress tests are combined with an associated imaging technique (nuclear or echocardiography). These kinds of tests are considered  “functional” or “physiologic.”
Coronary CT angiography (CTA), on the other hand, is a visualization of the actual anatomy of the coronary arteries, and has been proposed by many as a more useful starting point for evaluation of chest pain.

Prior to this study, there were no randomized comparisons of these two approaches on health outcomes in patients with stable chest pain. In patients with acute chest pain, presenting to the ER, two randomized controlled trials have shown superiority of CT angiography.

This morning at the American College of Cardiology meetings in San Diego, the results of the PROMISE (the PROspective Multicenter Imaging Study for Evaluation of Chest Pain) were presented.  Simultaneously with the presentation, the full paper was published here.

As a noninvasive cardiologist board-certified in both echocardiography and nuclear cardiology, and as a reader of coronary CT angiography,  I was particularly interested in hearing and reading these results.

The study was a well-done, realistic comparison of these two techniques. Over ten thousand patients presenting with stable chest pain were randomized to CTA versus stress testing at multiple different sites.

The composite primary end point was death, myocardial infarction, hospitalization for unstable angina, or major procedural complication. Secondary end points included invasive cardiac catheterization that did not show obstructive CAD and radiation exposure.

All tests were interpreted locally and the site clinical team made all subsequent care decisions. Stress MPI (nuclear) were ordered in 67%, stress echo in 23% and stress ECG in 10%. Pharmacologic stress was utiilized in 29%. The median follow up was 25 months.
The major finding was that there was no difference in occurrence of the primary end-point between the anatomic strategy (CTA, 3.0% at 25 months) and the functional strategy (stress testing, 3.3%).

My Take Home Points From the PROMISE Study

1. In the stable chest pain patient (even with significant risk factors) the prognosis is good.
2. We now have two roughly equivalent options for evaluating such patients, CTA or stress testing.
3. CTA is less likely to result in a cath with totally normal coronary arteries and it is useful for identifying early atherosclerosis. The patients in the CTA arm received more statins and aspirin due to this.
4. Currently, there are insurance companies which will not approve CTA for any indication other than congenital coronary artery anomaly. It is highly likely that this study will move CTA from a IIA indication to a I indication in guidelines and allow wider acceptance by insurance companies.

Skeptically Yours,

ACP.

9 thoughts on “PROMISEs, Promises: Stress Test or CT Angio for Patients With Stable Chest Pain”

  1. Great Blog. You hit on every area I would want my patients to know about–things we debate about every day. I market myself as a writer, but I’m a non-invasive cardiologist like you in New York and agree with your writings. Well done.
    Richie Smith
    Richard H. Smith MD

  2. Great blog and site, I don’t know if this particular blog is right spot but I didn’t know where to post this so here it goes, just looking for a bit of advice. I’m 58 year old Male, had a heart attack 11 years ago and had an angiogram done which indicated 40% blockage in the LAD and 20% in another location with no stents placed, since then I have had no real angina but had to get really warmed up to go hill climbing but other than that no symptoms at all. Within the last year I have had onset of angina after the following, walking hills, eating large meals, shovelling snow really quickly. I recently did the treadmill stress test and on the seventh minute starting having a small amount of the chest pains so my cardiologist stopped the test and indicated to me that I should have angiogram, which I have agreed to. Depending on the outcome of the angiogram they may well recommend stent or stents to be placed, at what percentage of blockage should one agree to have one? At rest I have no symptoms and can generally go for walks up to at least 4 mph also with no symptoms and for the most part feel real good.

    1. Current guidelines strongly recommend a trial of medical therapy (nitrates, calcium blockers, beta blockers) in patients with stable angina before proceeding to invasive interventions.
      The recent OPTIMA study which I discussed in my 2017 wrap-up post showed no benefit of stent placement in patients similar to you.
      The 10 year old COURAGE study showed no benefit of stents in preventing heart attacks or death out side the setting of an acute heart attack.
      Of course you should also be getting maximal risk factor modification (statins, exercise, lifestyle) and you should be taking a baby aspirin.

      1. Thank you for your quick response, I’m currently take baby aspirin, Lipitor, lipidil and Ramipril, I also have nitroglycerine which I have tried once which I was put on by the cardiologist at that time of the heart attack.
        In the last two months I have been on the treadmill everyday a minimum of 30 minutes and work out with weights 5 days a week and have been quite active over the last 11 years and plan on continuing to exercise at this rate. Since coming across your site I have been following your diet recommendations and drink usually a couple of drinks just on weekends. My biggest fear is not having this angiogram but getting a stent when I really don’t need it. Also Currently my LDL is 1.98 mmol/L and my HDL .92 mmol/L so I feel those under control and working to bring down the LDL. I’m due to have this angiogram on the 17th of this month I’ll keep you posted on how I make out. And I much appreciate your input and opinion on this matter, Thank you

  3. As noted above yesterday I had the angiogram through the wrist with no complications, the results where as follows: 80% Blocked in the LAD, and another adjoining artery had 50%, that’s the good news. The cardiologist didn’t place a stent as per the following. Aortic Valve Stenosis detected which he says needs open heart surgery soon, so he said since they will have my chest open they would do bypass on the LAD. I think my own cardiologist is going to do a echocardiogram first to concur. If you have any recommendations on tissue or mechanical valve replacement it would be appreciated as from what I have read I’m leaning to the tissue from an animal, if your interested in seeing my results of my angiogram note an email address and I will send.

    Thank you 🙂

  4. It’s very unusual for aortic stenosis that is severe enough for replacement surgery to not be diagnosed prior to catheterization. Typically there is a very prominent murmur and an echocardiogram easily makes the diagnosis. You definitely need an echocardiogram.
    Here’s what I tell patients regarding valve choice.
    The mechanical valves last forever but you have to take warfarin (although newer models are less thrombogenic, especially in the aortic position). The tissue valves do not require warfarin but degenerate after 10-15 years.
    It’s a decision the patient has to make after considering their own personal characteristics and preferences.

  5. Thank you for your reply, taking the warfarin doesn’t bug me as I’m already taking medication, I’m more concerned on the performance of either valve and how I will be able to get back to being active in walking and some form of weight training and of course just living a full life.

  6. Hi sorry for the delay as I’m now home finally after open heart surgery for replacing my Aortic Valve, I’m pleased that the doctors replaced it with On-X Valve, also at the same time they did the bypass on the LAD and the small blockage they also corrected as well, so now we are in the process of monitoring the warfarin and getting those numbers squared away, I just like thank you again for your comments on this site. One other question I have now is with diet now that I have had these procedures, would the Mediterranean diet still come into play with the modifications that you have indicated

    Thank you

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