Comparison of an Initial Risk-Based Testing Strategy vs Usual Testing in Stable Symptomatic Patients With Suspected Coronary Artery Disease

doi:10.1001/jamacardio.2023.2595

Coronary disease & ACSRandomised controlled trial

Comparison of an Initial Risk-Based Testing Strategy vs Usual Testing in Stable Symptomatic Patients With Suspected Coronary Artery Disease

JAMA CardiolPublished 1 Oct 2023

Randomised controlled trial
pragmatic
65 North American and European sites

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Authors' conclusion

An initial diagnostic approach to stable chest pain starting with quantitative risk stratification and deferred testing for minimal-risk patients and cCTA with selective FFR-CT in all others increased clinical efficiency relative to UT at 1 year.

Study context

Population: Stable symptomatic patients with suspected coronary artery disease (CAD) and no prior testing422 [20.1%] minimal risk
Participants: 2,103 patients

Comparison: Precision strategy vs usual testing
Precision strategy (PS)n = 1,057
Usual testing (UT)n = 1,046reference
Primary endpoint: Composite of:
Clinical efficiency (invasive catheterization without obstructive CAD)
Safety (death or nonfatal MI)
Follow-up: Median 11.8 months

Primary result

As reported in the abstract

Hazard ratio

0.35

95% CI 0.25–0.50

Events by treatment group

PS4.2%44 of 1057

UT11.3%118 of 1046

PS vs UT

HR 0.35 (95% CI 0.25–0.50)

Secondary outcomes

Outcome	PS	UT	Lower risk with PS ←→ Higher risk with PS	HR (95% CI)
Clinical efficiency: invasive catheterization without obstructive CAD	2.6%	10.2%		0.24 (0.16–0.36)
Death	0.5%	0.7%		0.71 (0.23–2.23)
Nonfatal MI	1.2%	0.5%		2.65 (0.96–7.36)
			0.10.31310Hazard ratio (log scale)

Lipid-lowering medication use · 1 year

P < 0.001

PS50.0%

UT41.8%

denominator PS 900 · UT 873

Antiplatelet medication use · 1 year

P < 0.001

PS35.7%

UT27.1%

denominator PS 900 · UT 873

Safety composite: death or nonfatal MI

Safety composite of death/MI similar: HR, 1.52; 95% CI, 0.73-3.15

Safety

Outcome	PS	UT	Lower risk with PS ←→ Higher risk with PS	HR (95% CI)
Nonfatal MI	1.2%	0.5%		2.65 (0.96–7.36)
			0.10.31310Hazard ratio (log scale)

Original publication

Comparison of an Initial Risk-Based Testing Strategy vs Usual Testing in Stable Symptomatic Patients With Suspected Coronary Artery Disease. JAMA Cardiol. Published 1 October 2023. doi:10.1001/jamacardio.2023.2595

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Summarised from the published abstract; every number is checked against it