BACKGROUND Stable chest pain is a common indication for cardiac catheterization. We assessed the prognostic value of the Prospective Multicenter Imaging Study for Evaluation (PROMISE) Minimal-Risk Tool in identifying patients who are at very low risk of obstructive coronary artery disease (CAD) or downstream cardiovascular adverse outcomes. METHODS We applied the PROMISE Minimal-Risk Tool to consecutive patients without known CAD who underwent elective cardiac catheterization for stable angina from January 1, 2000 to December 31, 2014 in the Duke Databank for Cardiovascular Disease (DDCD). Patients with scores >0.46 (top decile of lowest-risk from the PROMISE cohort) were classified as low-risk. Logistic regression modeling compared likelihood of freedom from obstructive coronary artery disease on index angiography, 2-year survival, and 2-year survival free of myocardial infarction (MI) and MI/revascularization between low- and non low-risk patients. Alternative cut points to define low- risk patients were also explored. RESULTS Among 6251 patients undergoing cardiac catheterization for stable chest pain, 1082 (17.3%) were low-risk per the PROMISE minimal-risk tool. Among low risk patients, obstructive coronary artery disease was observed in 14.9% and left main disease (≥ 50% Stenosis) was rare (0.9%). Compared with other patients, low risk patients had a higher likelihood of freedom from obstructive coronary disease on index catheterization (85.1% vs. 44.2%, OR 4.84, 95% CI 4.06-5.77). Low risk patients had significantly higher survival (98.2% vs. 94.4%, OR 3.18, 95% CI 1.99-5.08), MI-free survival (97.2% vs. 91.9%, OR 3.03, 95% CI 2.07-4.45), and MI/revascularization-free survival (86.2 vs. 59.9%, OR 4.19, 95% CI 3.48-5.05) at 2 years than non-low risk patients. Operating characteristics for predicting the outcomes of interest varied modestly depending on the low-risk cut-point used but the positive predictive value for 2 year freedom from death was >98% regardless. CONCLUSION The PROMISE minimal-risk tool identifies 17% of stable chest pain patients referred to cardiac catheterization as low risk. These patients have a low prevalence of obstructive CAD and better survival than non-low risk patients. While this suggests that these patients are unlikely to benefit from catheterization, further research is needed to confirm a favorable downstream prognosis with medical management alone.

中文翻译：

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估计 PROMISE 最小风险工具的实际性能。

背景稳定的胸痛是心导管插入术的常见指征。我们评估了前瞻性多中心影像评估研究 (PROMISE) 最小风险工具在识别阻塞性冠状动脉疾病 (CAD) 或下游心血管不良结局风险极低的患者方面的预后价值。方法 我们将 PROMISE 最小风险工具应用于 2000 年 1 月 1 日至 2014 年 12 月 31 日在杜克心血管疾病数据库 (DDCD) 中接受选择性心导管术治疗稳定型心绞痛的连续无已知 CAD 的患者。得分 >0.46（PROMISE 队列中最低风险的最高十分位数）的患者被归类为低风险。Logistic 回归模型比较了指数血管造影术中无阻塞性冠状动脉疾病的可能性、2 年生存率、低风险和非低风险患者之间无心肌梗死 (MI) 和 MI/血运重建的 2 年生存率。还探索了定义低风险患者的替代切点。结果 在 6251 名因稳定胸痛而接受心导管检查的患者中，根据 PROMISE 最小风险工具，1082 名 (17.3%) 为低风险。在低风险患者中，14.9% 的患者观察到阻塞性冠状动脉疾病，左主干病变（≥ 50% 狭窄）罕见（0.9%）。与其他患者相比，低风险患者在索引导管插入术中无阻塞性冠状动脉疾病的可能性更高（85.1% vs. 44.2%，OR 4.84，95% CI 4.06-5.77）。低风险患者的生存率（98.2% 对 94.4%，OR 3.18，95% CI 1.99-5.08）、无 MI 生存率（97.2% 对 91.9%，OR 3.03，95% CI 2.07-4.45）显着更高，和非低风险患者在 2 年时的 MI/无血运重建生存率（86.2 对 59.9%，OR 4.19，95% CI 3.48-5.05）。根据所使用的低风险临界点，预测感兴趣结果的操作特征略有不同，但无论如何，2 年免于死亡的阳性预测值 >98%。结论 PROMISE 最小风险工具将 17% 的稳定胸痛患者确定为低风险。与非低风险患者相比，这些患者的阻塞性 CAD 患病率低，存活率更高。虽然这表明这些患者不太可能从导管插入术中受益，但还需要进一步的研究来证实仅靠医疗管理的良好下游预后。根据所使用的低风险临界点，预测感兴趣结果的操作特征略有不同，但无论如何，2 年免于死亡的阳性预测值 >98%。结论 PROMISE 最小风险工具将 17% 的稳定胸痛患者确定为低风险。与非低风险患者相比，这些患者的阻塞性 CAD 患病率低，存活率更高。虽然这表明这些患者不太可能从导管插入术中受益，但还需要进一步的研究来证实仅靠医疗管理的良好下游预后。根据所使用的低风险临界点，预测感兴趣结果的操作特征略有不同，但无论如何，2 年免于死亡的阳性预测值 >98%。结论 PROMISE 最小风险工具将 17% 的稳定胸痛患者确定为低风险。与非低风险患者相比，这些患者的阻塞性 CAD 患病率低，存活率更高。虽然这表明这些患者不太可能从导管插入术中受益，但还需要进一步的研究来证实仅靠医疗管理的良好下游预后。结论 PROMISE 最小风险工具将 17% 的稳定胸痛患者确定为低风险。与非低风险患者相比，这些患者的阻塞性 CAD 患病率低，存活率更高。虽然这表明这些患者不太可能从导管插入术中受益，但还需要进一步的研究来证实仅靠医疗管理的良好下游预后。结论 PROMISE 最小风险工具将 17% 的稳定胸痛患者确定为低风险。与非低风险患者相比，这些患者的阻塞性 CAD 患病率低，存活率更高。虽然这表明这些患者不太可能从导管插入术中受益，但还需要进一步的研究来证实仅靠医疗管理的良好下游预后。