Coronary Heart Disease: CT Scans May Reduce Tests, Procedures and Radiation Exposure

Pamela S. Douglas, M.D. Duke University School of Medicine Duke University Medical Center Durham, NC Interview with:
Pamela S. Douglas, M.D.
Duke University School of Medicine
Duke University Medical Center
Durham, NC 27715

Medical Research: What is the background for this study?

Dr. Douglas: The primary objective of the PROMISE study was to compare the health outcomes of people who went to the doctor with new symptoms such as shortness of breath and/or chest pain that were suggestive of coronary artery disease and that required additional evaluation. This was an important investigation because no large research trial has ever been conducted to help guide the care of such patients. Instead, the selection of tests for such patients—which constitutes at least 4 million patients in the United States each year—has been largely left up to physician and patient preference rather than proven results.

Medical Research: What are the main findings?

Dr. Douglas: 10,003 patients from 193 different medical facilities across the US and Canada agreed to be part of the PROMISE study and  were randomized to a functional stress test or an anatomic test Using CT angiography.  The study found that the clinical outcomes of participants with suspected coronary artery disease were excellent overall, and were similar in terms of death and major cardiac conditions regardless of whether patients had a functional stress test or a computed tomographic scan. However, the CT scan may be better at ruling out the need for subsequent tests and procedures in patients who are free of heart disease, and involved a lower radiation exposure relative to a stress nuclear study. We also found, in a separately reported study, that the costs of the two diagnostic strategies were similar.

Medical Research: What should clinicians and patients take away from your report?

Dr. Douglas: Patients undergoing testing for suspected coronary artery disease have an excellent outcomes overall. The choice of test does not affect that outcome, but may provide a more efficient triage to the use of the cath lab, and lower radiation if the alternate choice is nuclear testing. Ultimately, the choice of test will depend on many factors, including clinical judgment and local expertise, but not cost.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Douglas: Although the excellent outcomes were achieved with all patients undergoing testing, events were so infrequent that a strategy of watchful waiting, or no testing, should be further examined. However this should be carefully investigated as we did not test this approach.


Outcomes of Anatomical versus Functional Testing for Coronary Artery Disease

Pamela S. Douglas, M.D., Udo Hoffmann, M.D., M.P.H., Manesh R. Patel, M.D., Daniel B. Mark, M.D., M.P.H., Hussein R. Al-Khalidi, Ph.D., Brendan Cavanaugh, M.D., Jason Cole, M.D., Rowena J. Dolor, M.D., Christopher B. Fordyce, M.D., Megan Huang, Ph.D., Muhammad Akram Khan, M.D., Andrzej S. Kosinski, Ph.D., Mitchell W. Krucoff, M.D., Vinay Malhotra, M.D., Michael H. Picard, M.D., James E. Udelson, M.D., Eric J. Velazquez, M.D., Eric Yow, M.S., Lawton S. Cooper, M.D., M.P.H., and Kerry L. Lee, Ph.D. for the PROMISE Investigators

N Engl J Med 2015; 372:1291-1300
April 2, 2015 Interview with: Pamela S. Douglas, M.D. (2015). Coronary Heart Disease: CT Scans May Reduce Tests, Procedures and Radiation Exposure 

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