AHA 2019: Data Highlight Differences in Discrimination of Noninvasive CAD Testing

November 18, 2019 – A new analysis of a DCRI study revealed that younger patients and older patients may need to undergo different types of testing for coronary artery disease in order to more accurately predict risk.

In middle-aged patients with stable symptoms suggestive of coronary artery disease (CAD), anatomic testing with coronary CT angiography (CTA) provided better prediction of risk, also known as prognostic discrimination.

Angela Lowenstern, MD

In contrast, functional (stress) testing provided better prognostic discrimination for older members of this patient population, according to a new analysis of the DCRI-led PROMISE study presented Monday by DCRI fellow Angela Lowenstern, MD, at the American Heart Association Scientific Sessions 2019 in Philadelphia.

“This study indicates that in patients with stable symptoms suggestive of CAD, there are important differences in presentation, test results, and prognostic capabilities of noninvasive testing across age,” Lowenstern said. “Specifically, coronary CTA offers additional risk stratification information for patients aged 45-64, with stress testing results associated with risk for cardiovascular death or myocardial infarction among patients 65 and above. These results support further exploration of age-specific approaches to the noninvasive evaluation of CAD.”

Suspected CAD is one of the most common, potentially life-threatening diagnostic problems encountered by clinicians. As many as five million patients with chest pain undergo noninvasive tests each year, with the goal of confirming the diagnosis and providing information about future risk.

Lowenstern was lead author of the AHA poster, titled “Differences in the Non-Invasive Evaluation for Coronary Artery Disease and Its Prognostic Implications by Patient Age: An Evaluation of the PROMISE Trial.” Other DCRI contributors were Karen Alexander, MD; C. Larry Hill, PhD; Brooke Alhanti, PhD; Michael Nanna, MD; Rajendra Mehta, MD; and Pamela Douglas, MD. The results were published simultaneously in JAMA Cardiology, with Lowenstern as lead author, and the same DCRI contributors.

Sponsored by Duke in collaboration with the National Heart Lung and Blood Institute (NHLBI), the PROMISE study was a prospective, randomized trial comparing the effectiveness of two initial diagnostic strategies—coronary computed tomographic angiography or functional testing—in patients with symptoms suggestive of CAD from 193 North American sites. A total of 8,966 patients were randomized to undergo testing and had interpretable results. The main outcome measure was a composite of cardiovascular death and myocardial infarction over a median follow-up of 25 months.

“Our findings indicate that there is no ‘one size fits all’ diagnostic strategy for patients with suspected coronary artery disease,” said Pamela Douglas, MD, PROMISE principal investigator and the senior author of the JAMA Cardiology publication. “Instead, physicians need to personalize imaging decisions by pursuing the best test for each individual patient after taking into consideration the growing body of data regarding imaging outcomes.”