Additive prognostic value of functional performance to coronary artery anatomy: the ISCHEMIA trial.

Clinical Snapshot

Key Findings

• P Value: P = 0.025

• Effect Size: HR 0.86 per MET increase for all-cause death

• Primary Outcome: All-cause death occurred in 69 patients during median 3.1 years follow-up

• Nnt Or Sensitivity: 10-20% improvement in predictive ability when adding peak METs to CCTA models

• Confidence Interval: 95% CI 0.76-0.98

Clinical Application

Highly feasible - exercise stress testing widely available in Australian cardiology practice Relevant to Australian practice where both EST and CCTA are PBS-supported investigations. Supports RACGP and CSANZ guidelines emphasising functional assessment in coronary disease Patients with chronic coronary disease and moderate-severe ischaemia undergoing risk stratification

Abstract

AIMS: To assess whether baseline functional performance assessed by exercise treadmill stress testing (EST) has additive value to coronary computed tomography angiography (CCTA) for risk stratification among patients with chronic coronary disease (CCD) and moderate or severe ischaemia. METHODS AND RESULTS: We performed a subgroup analysis of the ISCHEMIA trial including participants who underwent EST and CCTA. EST data and severity of coronary artery disease (CAD) on CCTA were evaluated by core laboratories, blinded to clinical data and results of the other tests. The primary outcome for this analysis was all-cause death. Secondary outcomes were cardiovascular death, cardiovascular death or myocardial infarction (MI), MI and a composite of cardiovascular death, MI, or hospitalization for heart failure, unstable angina, or resuscitated cardiac arrest. EST and the number of vessels diseased on CCTA were both interpretable in 1864 patients (median age 62 years, IQR 55-68, 83% males). During a median follow-up of 3.1 years, 69 patients died. Higher peak metabolic equivalents (METs) achieved on the qualifying stress test was associated with lower all-cause death (HR 0.86, 95% CI 0.76-0.98; P = 0.025). The addition of peak METs to CAD severity improved the predictive ability of the all-cause death and CV death models by 10-20% and 8-13% respectively, depending on the metrics used for CCTA. Adding peak METs to CCTA anatomical models resulted in better prediction of MI by 11-17%, cardiovascular death or MI by 10-14%, and 5-component composite outcome by 12-16%. CONCLUSION: Peak METs on EST, a marker of functional performance, added prognostic value to models including CCTA anatomical findings in patients with CCD and moderate or severe ischaemia.

References

1. 1.Maron, D. J., Hochman, J. S., Reynolds, H. R., Bangalore, S., O'Brien, S. M., Boden, W. E., Chaitman, B. R., Senior, R., López-Sendón, J., Alexander, K. P., Lopes, R. D., Shaw, L. J., Berger, J. S., Newman, J. D., Sidhu, M. S., Goodman, S. G., Ruzyllo, W., Gosselin, G., Maggioni, A. P., ... ISCHEMIA Research Group. (2020). Initial invasive or conservative strategy for stable coronary disease. New England Journal of Medicine, 382(15), 1395-1407. https://doi.org/10.1056/NEJMoa1915922