Duke Health Referring Physicians


Before Ordering Your Next Stress Test, Consider Patient's Age

New analysis recommends stratifying risk analysis

Treadmill stress test

A new analysis evaluating the prognostic value of coronary artery disease (CAD) tests reveals the potential need for clinicians to stratify risk more effectively by customizing techniques for specific age groups.

Published in JAMA Cardiology in November, the findings were based on data from the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE), the large-scale trial that used a pragmatic comparative effectiveness design.

Approximately 5 million patients presenting with chest pain undergo noninvasive tests each year to confirm a CAD diagnosis and provide information about future risk. Duke Clinical Research Institute (DCRI) Fellow Angela Lowenstern, MD, lead author, says the analysis focused on tests for three age categories using data from PROMISE.

The PROMISE trial, which was sponsored by Duke in collaboration with the National Heart Lung and Blood Institute, was a prospective, randomized trial comparing two testing strategies—coronary computed tomographic angiography (CTA) or functional testing. The age segmentation, Lowenstern says, offers new insights into the prognostic value of noninvasive testing based on patient age.

In a pre-specified sub analysis of the PROMISE data, Lowenstern and her colleagues evaluated three age categories to assess the prognostic value of the non-invasive tests: younger than 65 (6,378 individuals); between ages of 64 and 74 (2,062 individuals); greater than or equal to 75 (526 individuals)

“Our study centers around the age aspect,” Lowenstern says. “This analysis gives information that perhaps age should be incorporated into the decision-making process when choosing a non-invasive test to evaluate for coronary artery disease.” The PROMISE trial, which included more than 500 participants over age 75, allowed for a more robust analysis of this often-under-represented group of patients.

Key findings of the analysis:

  • Test result positivity increased with age, regardless of the noninvasive test completed.
  • Anatomic testing provided better prognostic results for patients younger than 65 years.
  • Functional testing was better able to distinguish future risk for patients 65 years and older with a significant relationship between age, test type, and prognosis.

“Specifically, coronary CTA offers additional risk stratification information for patients aged 45-64, with stress testing results associated with risk for cardiovascular death or myocardial infarction among patients 65 and above,” says Lowenstern. “These results support further exploration of age-specific approaches to the noninvasive evaluation of CAD.”

Other DCRI contributors to the study were Karen Alexander, MD; C. Larry Hill, PhD; Brooke Alhanti, PhD; Michael Nanna, MD; Rajendra Mehta, MD; and Pamela Douglas, MD.