Interpretation:

The PRECISE trial demonstrated that, compared with usual care, a risk stratification approach to guide cCTA with CT-FFR versus deferred testing in low-risk patients improved invasive testing efficacy and diagnostic yield without an increased risk of death or nonfatal MI at 1 year. The PROMISE and SCOT-HEART trials of cCTA previously demonstrated comparable or improved rates of major adverse cardiovascular events, respectively, versus usual care. However, the cCTA arms in both studies demonstrated increased rates of invasive coronary angiography referral during short-term follow-up. The PRECISE investigators utilized the PMRS, a validated risk stratification tool for suspected CAD, to achieve decreased rates of invasive coronary angiography overall and invasive coronary angiography without obstructive disease, as well as more frequent revascularization after invasive coronary angiography, following cCTA compared with usual care. In a prespecified secondary analysis, low-risk patients in either arm tended to be younger and majority women. Importantly, there were no episodes of death or nonfatal MI in the deferred testing subgroup, suggesting this approach was safe. Moreover, improvements in angina severity and frequency were identical to the usual care group despite no further CAD evaluation in 64% of the deferred testing group, suggesting that this approach was not associated with unresolved symptom burden. The pragmatic trial design limits comparison of cCTA against any specific initial testing strategy, which was quite heterogeneous in the UT arm.

Overall, the current results suggest that a PMRS-stratified approach to cCTA/CT-FFR, with deferred testing after shared decision-making with low-risk patients, is a safe and effective approach for the evaluation of CAD. Extended follow-up would provide valuable insight into whether the observed trends in reduced invasive coronary angiography and comparable cardiovascular safety in the PS arm extend beyond 1 year.