Changes in Medical Therapy and Lifestyle After Anatomical Versus Functional Testing for Coronary Artery Disease: The PROMISE Trial (PROspective Multicenter Imaging Study for Evaluation of Chest Pain)

Introduction: Diagnostic testing may represent a “teachable moment” for patients newly presenting with symptoms suggestive of CAD and requiring further evaluation, and may influence risk factor management, independent of test results. However, little is known about changes in medications and lifestyle after anatomical versus functional testing.

Hypothesis: Patients assigned to coronary CTA will report greater use of preventive medications and lifestyle practices.

Methods: We randomly assigned 10,003 symptomatic patients (53% women; mean age 61 yrs) to anatomical testing with CTA or functional testing (exercise ECG, nuclear stress, or stress echocardiography). We assessed use of preventive medications (aspirin, statin, beta blocker, and ACEi/ARB) and lifestyle practices (heart healthy diet, regular exercise, smoking, and obese/overweight status [BMI>25]) at 60 days. Chi-square tests assessed between-group changes (initiation or discontinuation). Multivariable logistic regression models assessed the association between testing strategy and prevalence of medication use or lifestyle practices.

Results: There were no differences in medications or lifestyle practices at baseline. At 60 days, the CTA strategy was associated with a higher proportion of patients newly initiating aspirin (11.6% vs 7.6%), statin (12.7% vs 6.2%), and beta blockers (8.2% vs 5.4%), compared to functional testing (p<0.0001 for each). The CTA strategy was also associated with a higher incidence of weight loss among obese/overweight patients (2.8% vs 2.4%), but the difference was not significant (p=0.051). Overall prevalences of aspirin (aOR=1.55), statin (aOR=2.04), and beta blocker (aOR=1.32) use were higher after CTA (p<0.001 for each). Eating a healthy diet (54.7% vs 50.8%) was increased after CTA (aOR=1.13 p=0.004), whereas obese/overweight status was reduced (aOR=0.79 p=0.047). Exercise and smoking cessation increased similarly in both arms. Benefits of CTA for statin use and weight loss persisted after adjusting for test results.

Conclusions: Among patients with suspected CAD, anatomical testing is associated with greater favorable changes in preventive medical and lifestyle practices. This may represent a long term benefit of a CTA testing strategy.