A PROMISE minimal risk score >0.46 identified 10.9% of patients with no MI or deaths and very low obstructive coronary disease risk, yet CTCA use was similar to high-risk patients.
Does the PROMISE minimal risk score accurately identify low-risk patients presenting with stable chest pain who can safely avoid further testing?
A PROMISE minimal risk score >0.46 identifies patients with stable chest pain at near-zero risk of short-term death or MI, suggesting further testing like CTCA could be safely omitted to save healthcare resources.
Absolute Event Rate: 0% vs 0%
Abstract Introduction Rapid Access Chest Pain Clinics (RACPC) were established in the United Kingdom for timely and effective assessment of patients presenting with recent onset stable chest pain. Despite clear guidelines there is wide variation in the referral, assessment and initial investigation of these patients. Recent data from the PRECISE study have demonstrated that the PROMISE minimal risk score (PMRS) can identify patients with recent onset stable chest pain who could safely be discharged without further testing. Despite this observation, the PMRS is not in widespread use. The aim of this analysis was therefore to retrospectively evaluate the performance of the PMRS in a real world population at our university hospital. Methods We performed a retrospective cohort analysis of all RACPC referrals from 03/04/2023 to 30/08/2024. All elements of the PMRS were measured, along with key patient outcomes including subsequent investigations and major adverse cardiovascular events (myocardial infarction (MI) and all-cause mortality). Statistical analyses were conducted in accordance with the data type and distribution. The cohort was split into low risk (PMRS0.46) and high risk (PMRS≤0.46) based on the PRECISE study. A Kaplan-Meier curve, with log rank analysis, was created to compare the incidence of death/MI between the high and low risk groups. Results The cohort included 3983 patients with a median age of 64 years (interquartile range (IQR) 55 – 75 years) and 49.5% female. The median PMRS was 0.102 (IQR 0.041- 0.257) with 10.9% (439) categorised as low risk (PMRS0.46). CTCA was requested in 107 patients (24.5%) in the low risk group (PMRS 0.46), versus 925 (26.1%) in the high risk (PMRS≤0.46) group (p=0.489). In the low risk group (PMRS 0.46) there were 3 CTCAs (0.7%) that demonstrated obstructive coronary disease and 13 CTCAs (3.0%) with minor coronary disease. At a median follow up of 306 days (IQR 177 - 428) there were no MI or deaths recorded in the low risk group (PMRS0.46). Figure 1 demonstrates the Kaplan Meier curve comparing incidence of death/MI between the two PMRS groups (0.46 and ≤0.46) (p = 0.002). Conclusion These data demonstrate that a PMRS 0.46 is associated with a very low frequency of significant coronary artery disease and no incidence of MI or death. Further, despite the low risk nature of these patients, the proportion for whom CTCA was requested was no different from higher risk patients. This suggests that PMRS could be safely instituted into clinical practice to exclude those patients at low risk from further investigations which would result in significant resource savings for healthcare services.
Tuffs et al. (Sat,) reported a other. A PROMISE minimal risk score >0.46 identified 10.9% of patients with no MI or deaths and very low obstructive coronary disease risk, yet CTCA use was similar to high-risk patients.