Diagnostic Strategies for the Evaluation of Chest Pain

Q: What is the clinical evidence from this study?

Study design: Review. Population: Stable chest pain of suspected cardiac etiology. Intervention: Coronary computed tomography angiography (CCTA) vs. Usual care or functional stress testing (exercise treadmill testing, nuclear stress testing, or stress echocardiography).

Q: What does this research mean for the field?

Coronary computed tomography angiography improves diagnostic certainty of coronary heart disease and achieves clinical event rates comparable to functional testing in patients with stable chest pain. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

Christopher B. Fordyce; David Ernest Newby; Pamela S. Douglas

doi:10.1016/j.jacc.2015.11.055

February 1, 2016Journal of the American College of CardiologyOpen Access

Diagnostic Strategies for the Evaluation of Chest Pain

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Why the study?

Well-recognized knowledge gaps exist despite the widespread use of noninvasive imaging for stable chest pain. This review distills data from the pivotal SCOT-HEART and PROMISE trials to inform clinicians in selecting noninvasive testing.

Does coronary computed tomography angiography improve diagnostic certainty, clinical management, and cardiovascular outcomes compared with functional stress testing or usual care in patients with stable chest pain?

Key Points

Synthesize evidence from the SCOT-HEART and PROMISE randomized trials to guide clinicians in selecting noninvasive diagnostic imaging tests for stable chest pain.
Narrative review comparing two multicenter randomized trials: SCOT-HEART (N=4,146) evaluating CCTA plus usual care versus usual care alone, and PROMISE (N=10,003) comparing CCTA to functional stress testing.
Evaluation of diagnostic certainty, noninvasive and invasive procedural pathways, cumulative radiation doses, and cardiovascular clinical outcomes.
In SCOT-HEART, CCTA increased the certainty of CAD diagnosis (relative risk: 2.56; 95% CI: 2.33 to 2.79) and secondary cardiovascular death or myocardial infarction rate was 0.62 (95% CI: 0.38 to 1.01; p = 0·0527) at 20 months.
In PROMISE, the composite primary endpoint of death, MI, hospitalization for unstable angina, or major procedural complication occurred at similar rates between CCTA and functional testing (3.3% vs. 3.0%) over a median follow-up of 25 months.

Structured PICO

Does coronary computed tomography angiography improve diagnostic certainty, clinical management, and cardiovascular outcomes compared with functional stress testing or usual care in patients with stable chest pain?

P

Population

Narrative review examining patients with stable chest pain evaluated across major randomized trials including SCOT-HEART (n=4,146) and PROMISE (n=10,003) followed for a median of 20 to 25 months.

I

Intervention

Coronary computed tomography angiography (CCTA) used either in addition to usual care (sequential with exercise ECG in SCOT-HEART) or as an initial anatomic diagnostic strategy (in PROMISE).

C

Comparator

Usual care alone (predominantly exercise ECG testing in SCOT-HEART) or initial functional stress testing (exercise treadmill testing, nuclear stress myocardial perfusion imaging, or stress echocardiography in PROMISE).

Synthesis of the landmark SCOT-HEART and PROMISE trials demonstrates that coronary CT angiography safely enhances diagnostic certainty and optimizes selection for invasive angiography compared with functional testing in stable chest pain, supporting a broader role for CCTA in clinical practice.

Limitations

Neither SCOT-HEART nor PROMISE included a 'no-testing' control arm
Overall clinical event rates in both reviewed trials were low, making hard clinical endpoints challenging to meet in this low-risk population
Neither SCOT-HEART nor PROMISE included a 'no-testing' arm despite low overall event rates
Low overall clinical event rates in both reviewed trials made hard clinical endpoints challenging to meet and potentially left PROMISE underpowered

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Implication

Informs noninvasive imaging selection in stable chest pain; leaves open optimal individualized strategies.

Abstract

SCOT-HEART and PROMISE represent the 2 largest and most comprehensive cardiovascular imaging outcome trials in patients with stable chest pain, and provide significant insights into patient diagnosis, management, and outcomes. These trials are particularly timely, given the well-recognized knowledge gaps and widespread use of noninvasive imaging. The overall goal of this review is to distill the data generated from these 2 pivotal trials to better inform the practicing clinician in the selection of noninvasive testing for stable chest pain. Similarities and differences between SCOT-HEART and PROMISE are highlighted, and clinical and practical implications discussed. Both trials show that CCTA should have a greater role in the diagnostic pathway of patients with stable chest pain.

Discussion

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Cite This Study

Fordyce et al. (2016) conducted a review in Stable chest pain of suspected cardiac etiology. Coronary computed tomography angiography (CCTA) vs. Usual care or functional stress testing (exercise treadmill testing, nuclear stress testing, or stress echocardiography) was evaluated.

synapsesocial.com/papers/6aeba07def9e8ef699a0eeab https://doi.org/10.1016/j.jacc.2015.11.055

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Diagnostic Strategies for the Evaluation of Chest Pain

Key Points

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Diagnostic Strategies for the Evaluation of Chest Pain

Key Points

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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