Retrospective analysis of the performance of the PROMISE minimal risk tool for patients presenting with recent onset stable chest pain

Abstract

Introduction: the PRECISE study demonstrated that the Prospective multicentre imaging study for evaluation of chest pain (PROMISE) Minimal risk score (PMRS) can identify patients with recent onset stable chest pain who could safely be reassured and discharged without further testing. Despite this observation, the PMRS is not in widespread use. The aim of this analysis was therefore to retrospectively evaluate the performance of the PMRS had it been applied as a decision tool in a real-world population.

Methods: we performed a retrospective cohort analysis of all stable chest pain referrals from 03 April 2023 to 30 August 2024. All elements of the PMRS were measured, along with key patient outcomes including subsequent investigations and cardiovascular events (myocardial infarction (MI) and all-cause mortality). Statistical analyses were conducted in accordance with the data type and distribution. The cohort was split into the minimal risk cohort (PMRS >0.46) and the remainder of the cohort (PMRS ≤0.46). A Kaplan-Meier curve, with log rank analysis, was created to compare the incidence of death/MI between the minimal risk and the remainder of the cohort. 

Results: this analysis included 3983 patients with a median age of 64 years (IQR 55–75 years) and 49.5% female. The median PMRS was 0.102 (IQR 0.041–0.257) with 10.9% (436) categorised as minimal risk (PMRS >0.46). In the minimal risk group, there were three CT coronary angiographies (0.7%) that demonstrated obstructive coronary disease. At a median follow-up of 306 days (IQR 177–428) there were no MI or deaths recorded in the minimal risk group. 

Conclusion: these data demonstrate that a PMRS >0.46 is associated with a very low frequency of significant coronary artery disease and MI or death. This proof of concept suggests that PMRS could be safely instituted into clinical practice to defer those patients at minimal risk from further investigations which would result in significant resource savings for healthcare services.

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