heart attack Archives - The Imaging Wire

Coronary CT angiography works just as well as traditional stress testing over the long haul for patients with stable symptoms of coronary artery disease. That’s according to the latest follow-up data from the PROMISE study in JAMA Cardiology, which found no difference in mortality between either strategy.

PROMISE was a randomized controlled trial that compared patient work-up with anatomical CCTA scans to functional stress testing (exercise ECG, stress echo, or stress nuclear) in 10k patients from 2010 to 2014.

The first PROMISE results found that in patients with CAD symptoms who were followed up for just over two years, there was little difference between anatomical CCTA and functional stress testing for endpoints like death, myocardial infarction, or other complications.

But what about over a longer follow-up period? The new results extend PROMISE’s follow-up to a median of 10.6 years, finding…

Mortality rates were largely the same whether patients got CCTA or stress testing (14.3% vs. 14.5%, p = 0.56).
Cardiovascular mortality rates were also similar (4.0% vs. 4.3%, p = 0.77).
As were noncardiovascular death rates (10.7% for both).

There were some differences in the predictive power of each modality based on patient characteristics…

With CCTA, any abnormal finding increased a patient’s mortality risk compared to normal findings for severe, moderate, and mild disease (HR = 3.44, 3.38, and 1.99, respectively).
With stress testing, only patients with severely abnormal disease had higher mortality risk (HR = 1.45).

The new PROMISE data also tracks well with recent 10-year findings from SCOT-HEART, another major study that demonstrated CCTA’s value.

Combining results from PROMISE and SCOT-HEART shows 89% survival of patients with stable angina at 12 years, demonstrating good effectiveness regardless of workup strategy.

The Takeaway

PROMISE findings have gone a long way toward showing that CCTA is every bit as effective as stress testing, and the new results reinforce this message. The findings are also good news for radiology, which has a stronger hold over anatomical imaging with CT than it does over the predominant stress modalities, which are largely controlled by cardiology.

CT should be used first to evaluate patients with stable chest pain who are suspected of having a heart attack. That’s the message of a paper being presented this week at the American College of Cardiology Cardiovascular Summit in Washington, DC.

CT is proving itself useful for a variety of applications in cardiac imaging, from predicting heart disease risk through coronary calcium scores to assessing whether people with chest pain need treatment like invasive angiography – or can be sent home and monitored.

But cardiac CT often runs up against decades of clinical practice that relies on tools like stress testing or diagnostic invasive coronary angiography for evaluating patients, with the CT-first strategy reserved for a limited number of people, such as those with unestablished coronary artery disease.

But the new study suggests that the CT-first approach could be used for the vast majority of patients presenting with stable chest pain.

A research team led by senior author Markus Scherer, MD, of Atrium Health-Sanger Heart & Vascular Institute in Charlotte, North Carolina tested the strategy in 786 patients seen from October 2022 to June 2023 who had no prior diagnosis of coronary artery disease and underwent elective invasive angiography to evaluate suspected angina.

The CT-first strategy compared CT angiography with provisional FFRCT testing to traditional evaluation pathways, which included stress echo, stress myocardial perfusion imaging, stress MRI, or no invasive testing before direct referral to angiography. Revascularization rates by strategy were as follows …

62% for CT-first
50% for stress MRI
40% for stress echo
34% for no prior test
31% for stress MPI

The Takeaway

The results presented this week offer real-world evidence that support recent clinical studies backing broader use of CT for patients with chest pain. Given CT’s advantages in terms of cost and noninvasiveness, the findings raise the question of whether more can be done to get clinicians to adhere to established guidelines calling for a CT-first protocol.

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