Comparison of an Initial Risk-Based Testing Strategy vs Usual Testing in Stable Symptomatic Patients With Suspected Coronary Artery Disease: The PRECISE Randomized Clinical Trial

This randomized clinical trial investigates the optimal initial evaluation pathway to reduce unnecessary testing referral for patients with suspected coronary artery disease who are symptomatic but in stable condition. Key PointsQuestionWhat is the optimal initial evaluation pathway to reduce unnecessary testing and catheterization referral for stable, symptomatic patients with suspected coronary artery disease (CAD)? FindingsIn this randomized clinical trial including 2103 participants, prior to any testing, a precision strategy using the validated Prospective Multicenter Imaging Study for the Evaluation of Chest Pain (PROMISE) minimal risk score to guide deferred testing for minimal-risk patients and coronary computed tomographic angiography with selective fractional flow reserve for all others improved clinical efficiency (catheterization without obstructive CAD) with no statistically significant impact on safety (death, nonfatal myocardial infarction) at 1 year. MeaningThe precision strategy is a clinically efficient and potentially safe initial approach for evaluating patients with new-onset stable symptoms and suspected CAD. ImportanceTrials showing equivalent or better outcomes with initial evaluation using coronary computed tomography angiography (cCTA) compared with stress testing in patients with stable chest pain have informed guidelines but raise questions about overtesting and excess catheterization. ObjectiveTo test a modified initial cCTA strategy designed to improve clinical efficiency vs usual testing (UT). Design, Setting, and ParticipantsThis was a pragmatic randomized clinical trial enrolling participants from December 3, 2018, to May 18, 2021, with a median of 11.8 months of follow-up. Patients from 65 North American and European sites with stable symptoms of suspected coronary artery disease (CAD) and no prior testing were randomly assigned 1:1 to precision strategy (PS) or UT. InterventionsPS incorporated the Prospective Multicenter Imaging Study for the Evaluation of Chest Pain (PROMISE) minimal risk score to quantitatively select minimal-risk participants for deferred testing, assigning all others to cCTA with selective CT-derived fractional flow reserve (FFR-CT). UT included site-selected stress testing or catheterization. Site clinicians determined subsequent care. Main Outcomes and MeasuresOutcomes were clinical efficiency (invasive catheterization without obstructive CAD) and safety (death or nonfatal myocardial infarction [MI]) combined into a composite primary end point. Secondary end points included safety components of the primary outcome and medication use. ResultsA total of 2103 participants (mean [SD] age, 58.4[11.5] years; 1056 male [50.2%]) were included in the study, and 422 [20.1%] were classified as minimal risk. The primary end point occurred in 44 of 1057 participants (4.2%) in the PS group and in 118 of 1046 participants (11.3%) in the UT group (hazard ratio [HR], 0.35; 95% CI, 0.25-0.50). Clinical efficiency was higher with PS, with lower rates of catheterization without obstructive disease (27 [2.6%]) vs UT participants (107 [10.2%]; HR, 0.24; 95% CI, 0.16-0.36). The safety composite of death/MI was similar (HR, 1.52; 95% CI, 0.73-3.15). Death occurred in 5 individuals (0.5%) in the PS group vs 7 (0.7%) in the UT group (HR, 0.71; 95% CI, 0.23-2.23), and nonfatal MI occurred in 13 individuals (1.2%) in the PS group vs 5 (0.5%) in the UT group (HR, 2.65; 95% CI, 0.96-7.36). Use of lipid-lowering (450 of 900 [50.0%] vs 365 of 873 [41.8%]) and antiplatelet (321 of 900 [35.7%] vs 237 of 873 [27.1%]) medications at 1 year was higher in the PS group compared with the UT group (both P<.001). Conclusions and RelevanceAn 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. Additional randomized clinical trials are needed to verify these findings, including safety. Trial RegistrationClinicalTrials.gov Identifier: NCT03702244