- Question
- Does an initial risk-based strategy (PROMISE minimal-risk score, with coronary CTA and selective FFR-CT for those not at minimal risk) improve clinical efficiency compared with usual testing in stable symptomatic patients with suspected coronary artery disease?
- Design
- Pragmatic, open-label (unmasked) randomized trial with 1:1 allocation, enrolling 2103 participants at 65 North American and European sites between December 2018 and May 2021. Median follow-up was 11.8 months.
- Population
- Patients with stable symptoms suggestive of coronary artery disease and no prior testing. A total of 20.1% were classified as minimal risk by the score.
- Intervention
- Precision strategy: minimal-risk patients by the PROMISE score had testing deferred, while all others were assigned to coronary CTA with selective FFR-CT. Subsequent care was determined by site clinicians.
- Control
- Usual testing: site-selected stress testing or catheterization, with subsequent care at clinician discretion.
- Primary outcome
- Composite of clinical efficiency and safety: invasive catheterization without obstructive coronary artery disease, death, or nonfatal myocardial infarction at 1 year.
- Results
- The primary end point occurred in 44 of 1057 participants (4.2%) in the precision strategy group and 118 of 1046 (11.3%) in the usual testing group (HR 0.35; 95% CI 0.25-0.50). Catheterization without obstructive disease occurred in 2.6% vs 10.2% (HR 0.24; 95% CI 0.16-0.36).
- Safety
- The death/MI safety composite was similar between groups (HR 1.52; 95% CI 0.73-3.15). Nonfatal MI occurred in 13 participants (1.2%) vs 5 (0.5%) (HR 2.65; 95% CI 0.96-7.36), and death in 5 (0.5%) vs 7 (0.7%). At 1 year, lipid-lowering and antiplatelet medication use was higher with the precision strategy (both P < .001).
- Conclusion
- A strategy combining quantitative risk stratification, deferred testing in minimal-risk patients, and coronary CTA with selective FFR-CT increased clinical efficiency at 1 year compared with usual testing, although the authors note that further trials are needed to verify these findings, including safety.
- Why it matters
- It supported coronary CTA as a first-line test in stable chest pain and added the idea of tailoring the strategy to patient risk to reduce unnecessary catheterization, with the caveat that safety requires confirmation.
Card generated automatically with AI from the abstract of the original publication and the trial registry; every figure was checked against those sources. It may contain errors: verify the data at the source before using it for clinical decisions.
Generated on October 18, 2026