Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Multicenter Study
. 2022 Aug;15(8):1442-1454.
doi: 10.1016/j.jcmg.2022.03.009. Epub 2022 May 11.

The PROMISE Minimal Risk Score Improves Risk Classification of Symptomatic Patients With Suspected CAD

Laust D Rasmussen  1 , Christopher B Fordyce  2 , Louise Nissen  3 , C Larry Hill Jr  4 , Brooke Alhanti  4 , Udo Hoffmann  5 , James Udelson  6 , Morten Bøttcher  7 , Pamela S Douglas  4 , Simon Winther  7
Affiliations
Free article
Multicenter Study

The PROMISE Minimal Risk Score Improves Risk Classification of Symptomatic Patients With Suspected CAD

Laust D Rasmussen et al. JACC Cardiovasc Imaging. 2022 Aug.
Free article

Abstract

Background: Guidelines for evaluating patients with suspected coronary artery disease (CAD) recommend pretest probability (PTP) estimation but provide no clear recommendations regarding diagnostic testing in patients with >5% to 15% risk of obstructive CAD. The diagnostic and prognostic value of PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) minimal risk score (PMRS) calculation in this patient group is unknown.

Objectives: This work aims to improve the evaluation of stable patients with suspected CAD by using the PMRS, which identifies patients at minimal risk of CAD and events in patients with >5% to 15% PTP of obstructive CAD.

Methods: Greater than 5% to 15% PTP patients from 2 large clinical trials were used for subcohort derivation: PROMISE (N = 10,003) and Dan-NICAD (Danish study of Non-Invasive Testing in Coronary Artery Disease) (N = 3,252). First, the PMRS cutoff associated with a prevalence of obstructive CAD ≤5% was determined in the >5% to 15% PTP PROMISE core lab computed tomographic angiography patients (discovery cohort: n = 2,191). This cutoff was validated for obstructive CAD in >5% to 15% PTP Dan-NICAD patients (CAD validation cohort: n = 1,386) and for prognostic impact on death and myocardial infarction in >5% to 15% PTP PROMISE non-core lab computed tomographic angiography patients (prognosis validation cohort: n = 2,753).

Results: In the discovery cohort, a CAD prevalence of ≤5% was found at a PMRS of ≥34%. In the CAD validation cohort, this cutoff down-classified 442 (31.9%) of >5% to 15% PTP patients into the low PTP group (CAD ≤5%); the prevalence of obstructive CAD in down-classified patients was 3.2% compared to 7.1% in non-down-classified patients. A PMRS ≥34% was nonsignificantly associated with a lower risk of myocardial infarction and death in the prognosis validation cohort (HR: 0.58 [95% CI: 0.29-1.18]; P = 0.13).

Conclusions: For evaluating patients with suspected CAD, a combined use of traditional PTP and the PMRS correctly down-classified one-third of >5% to 15% PTP patients into a group with very low prevalence of obstructive CAD and adverse events. The proposed strategy may improve risk stratification and help reduce unneeded diagnostic testing.

Keywords: chronic coronary syndrome; clinical likelihood; coronary artery disease; major adverse cardiac events; minimal risk score; pretest probability.

PubMed Disclaimer

Conflict of interest statement

Funding Support and Author Disclosures The study was supported by The Danish Heart Foundation (Grant No. 15-R99-A5837-22920), the Health Research Fund of Central Denmark Region, and Aarhus University Research foundation. The PROMISE trial was supported by grants from the National Heart, Lung, and Blood Institute (R01HL098237, R01HL098236, R01HL098305 and R01HL098235). Dr Fordyce has received consulting fees from Bayer, Novo Nordisk, Boehringer Ingelheim, Sanofi, Pfizer, and Amgen; and has received research grants from Bayer outside of this work. Dr Bøttcher has been a member of the advisory board and has had research collaboration with Novo Nordisk, AstraZeneca, Bayer, Sanofi, Boehringer Ingelheim, Novartis, BMS-Pfizer, and Acarix outside of this work. Dr Douglas has received research funding from HeartFlow outside of this work. Dr Winther has received support from the Novo Nordisk Foundation Clinical Emerging Investigator grant (NNF21OC0066981). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Comment in

  • A PROMISE to Reduce Low-Value Testing.
    Redberg RF, Guduguntla V. Redberg RF, et al. JACC Cardiovasc Imaging. 2022 Aug;15(8):1455-1457. doi: 10.1016/j.jcmg.2022.04.018. Epub 2022 Jun 15. JACC Cardiovasc Imaging. 2022. PMID: 35926904 No abstract available.

Publication types