Key result
The PROMISE minimal-risk tool improved prognostic discrimination compared with the CADC model (c-statistic 0.785 vs 0.730, p < 0.001) in patients with suspected stable angina.
Why the study?
Does the PROMISE minimal-risk tool improve prognostic discrimination compared to the CADC model in patients with suspected stable angina?
Observational (n=1,764)
Yes
Does the PROMISE minimal-risk tool improve prognostic discrimination compared to the CADC model in patients with suspected stable angina?
Absolute Event Rate: 0.785% vs 0.73%
p-value: p=<0.001
The PROMISE minimal-risk tool outperforms the CADC model in prognostic discrimination for patients with suspected stable angina, potentially aiding decisions on non-invasive testing.
May aid low-risk identification in stable angina; extends external validation but leaves adoption open pending outcome trials.
BackgroundThe PROspective Multicenter Imaging Study for Evaluation of chest pain (PROMISE) minimal-risk tool was recently developed to identify patients with suspected stable angina at very low risk of coronary artery disease (CAD) and clinical events. We assessed the external validity of this tool within the context of the Scottish Computed Tomography of the HEART (SCOT-HEART) multicenter randomised controlled trial of patients with suspected stable angina due to coronary disease.MethodsThe minimal-risk tool was applied to 1764 patients with complete imaging and follow-up data. External validity was compared with the guideline-endorsed CAD Consortium (CADC) risk score and determined through tests of model discrimination and calibration.ResultsA total of 531 (30.1%, mean age 52.4 years, female 62.0%) patients were classified as minimal-risk. Compared to the remainder of the validation cohort, this group had lower estimated pre-test probability of coronary disease according to the CADC model (30.0% vs 47.0%, p < 0.001). The PROMISE minimal-risk tool improved discrimination compared with the CADC model (c-statistic 0.785 vs 0.730, p < 0.001) and was improved further following re-estimation of covariate coefficients (c-statistic 0.805, p < 0.001). Model calibration was initially poor (χ2 197.6, Hosmer-Lemeshow [HL] p < 0.001), with significant overestimation of probability of minimal risk, but improved significantly following revision of the PROMISE minimal-risk intercept and covariate coefficients (χ2 5.6, HL p = 0.692).Conclusion and relevanceDespite overestimating the probability of minimal-risk, the PROMISE minimal-risk tool outperforms the CADC model with regards to prognostic discrimination in patients with suspected stable angina, and may assist clinicians in decisions regarding non-invasive testing.Trial registrationClinicalTrials.gov identifier: NCT01149590
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Adamson et al. (2017) conducted an observational in suspected stable angina (n=1,764). PROMISE minimal-risk tool vs. CAD Consortium (CADC) risk score was evaluated on prognostic discrimination (c-statistic) (p=<0.001). The PROMISE minimal-risk tool improved prognostic discrimination compared with the CADC model (c-statistic 0.785 vs 0.730, p < 0.001) in patients with suspected stable angina.
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