Precision Medicine Strategy Reduced Testing in Patients With Chest Pain - Medpage Today

CHICAGO -- As galore arsenic 10% of clinicians volition nonstop their patients with thorax symptom straight to the cath lab, but a caller survey showed that this usual-care strategy is little effectual successful reducing atrocious outcomes and wastes resources compared with a precision strategy.

Overall, patients pursuing precision medicine protocols had a 71% reduced hazard of experiencing a composite superior endpoint of death, myocardial infarction, oregon catheterization with oregon without obstructive coronary artery illness versus patients whose doctors utilized champion judgement successful ordering attraction (adjusted HR 0.29, 95% CI 0.20-0.41, P<0.001), reported Pamela Douglas, MD, of the Duke Clinical Research institute successful Durham, North Carolina, during the American Heart Association yearly meeting.

"The PRECISE survey provides the archetypal randomized grounds for a risk-based investigating strategy to trim other investigating and amended ratio of care, portion maintaining fantabulous diligent outcomes, specified arsenic utilizing guideline-directed medications, reducing thorax pain, and minimizing the fig of bosom attacks oregon bosom disease-related deaths," she said during a property conference.

Four percent of the precision strategy radical (n=44) experienced the superior composite endpoint compared with 11.3% of usual-care patients (n=118), mostly driven by the fig of patients who were sent for catheterization (2.6% and 10.2%, respectively).

In the precision group, obstructive coronary artery illness was identified successful 108 patients compared with 70 successful the usual-care group.

"There were nary deaths oregon myocardial infarction events successful the precision strategy participants who were assigned to deferral testing," Douglas noted, adding that successful astir each subgroup, the results favored the precision strategy.

"We were pleasantly amazed by the reduced usage of investigating successful the precision attraction group, much businesslike usage of bosom catheterization, and enhanced preventive medicine use, each of which constituent to semipermanent benefits for patients' health," she added. "Our findings whitethorn assistance with evaluating the millions of radical globally each twelvemonth who spot their doctors with unchangeable thorax symptom by accurately identifying those astatine debased hazard for objective events who tin safely hold diagnostic testing."

Patients experiencing thorax discomfort successful the precision investigating limb of the proceedings were classified by their doctors according to the PROMISE Minimal Risk Tool, which calculates a people based connected age; sex; contention and ethnicity; past of hypertension, diabetes, oregon dyslipidemia; household past of premature coronary artery disease; smoking status; symptoms unrelated to carnal oregon intelligence stress; and high-density lipoprotein cholesterin level.

If patients successful the precision strategy radical were deemed to beryllium precocious risk, they were sent for a coronary CT angiogram with oregon without CT-derived fractional travel reserve (FFR) testing, portion those who were deemed debased hazard had investigating deferred.

Commenting connected the study, designated discussant Julia Indik, MD, PhD, of the University of Arizona College of Medicine successful Tucson, said that 1 of the reasons the survey is important is that it whitethorn forestall a cascade of unnecessary testing.

"It is analyzable knowing what to bash with a diligent who comes to the bureau with thorax pain," she noted. "When you execute a trial connected the patient, determination is the anticipation of having a mendacious positive, and past we taxable patients to much tests, riskier tests, angiographic tests, and that tin incur further hazard and costs."

Indik said the extremity of PRECISE was to absorption connected which patients truly request further testing. "And it did amusement that pursuing the PRECISE algorithm, unnecessary tests could beryllium avoided."

She added that the imaginable of PRECISE and different studies presented astatine the gathering are being muted by the request for much staff, particularly aft losses incurred during the COVID-19 pandemic. "We besides person to amended our cardiologists connected however to trim testing," she said.

In PRECISE, 1,047 patients were treated according to the precision protocol -- 21% were thought to beryllium debased hazard and 89% of that radical were not tested, portion 11% were fixed further tests. In the usual-care cohort of 1,046 patients, 21% were besides deemed to beryllium astatine debased risk, but 89% of them were tested.

Of the patients astatine precocious hazard successful the precision group, 48% went connected to person a coronary CT angiogram, and different 31% received a coronary CT angiogram positive FFR testing, portion 1% had a treadmill ECG ordered, and 2% each were tested with accent echocardiography oregon SPECT/PET. In 16% of the cases, nary tests were ordered.

In contrast, 32% of the usual-care patients underwent SPECT/PET, 30% were tested with accent echocardiography, 11% had a treadmill ECG ordered, 10% underwent cardiac MRI accent testing, 10% were sent straight for cardiac catheterization, and 7% were not fixed immoderate tests.

Across some groups, mean property was 58-59, 48% to 52% were women, 16% were successful a radical oregon taste number group, and 94% had astatine slightest 1 large cardiovascular hazard factor.

Limitations to the survey included the inability to cognize outcomes that occurred extracurricular the 12-month survey period, Douglas said, adding that costs and benefits are inactive being studied.