Presenting symptoms in low-risk outpatients not always associated with higher baseline CAD risk

Typicality of coronary artery disease (CAD) symptoms was not closely associated with higher baseline risk but was related to differences in care and the prognostic value of a positive noninvasive test result, a study found.

Researchers examined the association between four presenting symptoms (substernal/left-sided chest pain, other chest/neck/arm pain, dyspnea, and other symptoms) and patient risk, noninvasive test results, clinical management, and outcomes as a secondary analysis of stable outpatients randomized in the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial. The goal of the current study was to determine the relationship between symptoms at presentation and the resulting processes of care, test results, and clinical outcomes. Differences in noninvasive test result, all-cause death/myocardial infarction/unstable angina hospitalization, and cardiovascular death/myocardial infarction were reviewed by symptom type. The primary end points were a composite of all-cause death, myocardial infarction (MI), and unstable angina hospitalization and the composite of cardiovascular death or MI. Results were published April 4 by Circulation: Cardiovascular Quality and Outcomes.

A total of 9,996 patients were included in the study. The mean age was 60.0 years, 52.7% were women, and 15.6% were non-White. Most presented with chest pain (47.2% substernal or left chest pain, 29.2% other chest pain), followed by dyspnea (14.9%) and other symptoms (8.7%), and most presented with at least one secondary symptom. The most common secondary symptom was dyspnea, which was reported in 26.3% of patients. Patients with dyspnea were older (median age, 63 years; P≤0.02) with higher baseline risk (78.2% with atherosclerotic cardiovascular disease >7.5% vs. 67.6%; P≤0.02).

Patients presenting with dyspnea or substernal chest pain had the highest prognostic value of a positive noninvasive test. Test-positive patients with dyspnea (adjusted odds ratio, 0.66; 95% CI, 0.51 to 0.85) or other symptoms (adjusted odds ratio, 0.65; 95% CI, 0.47 to 0.90) were less likely to be referred for cardiac catheterization. No association was seen between symptom type and outcome, but symptom presentation with chest pain or dyspnea modified the association between a positive noninvasive test and clinical outcome (P=0.025 for the interaction between both all-cause death/myocardial infarction/unstable angina hospitalization and cardiovascular death/MI).

The researchers concluded that presenting symptoms correlated with significant differences in baseline risk profiles and subsequent processes of care in low-risk patients with stable symptoms being evaluated for possible CAD in the PROMISE trial. “Despite these differences, symptom presentation was not associated with a higher likelihood of a positive [noninvasive test] result or adverse clinical outcomes. However, the prognostic value of a positive test was modified by symptom presentation, with the highest prognostic value among patients presenting with dyspnea or substernal chest pain,” the authors wrote. They noted that their findings underscore the difficulty of predicting obstructive CAD or outcomes based on presentation symptoms alone and the importance of using symptom presentation to help inform the positive predictive value of noninvasive testing and guide subsequent management.