Clinical question: When evaluating the intermediate-risk patient with chest pain, should coronary computed tomography angiography (CCTA) be used instead of myocardial perfusion imaging (MPI)?
Background: CCTA has been shown in prior randomized controlled trials to save time and money compared to other protocols, including stress ECG, echocardiogram, and MPI. Less information is available as to whether CCTA provides a better selection of patients for cardiac catheterization compared to MPI.
Study design: Randomized, controlled, comparative effectiveness trial.
Setting: Telemetry ward of an urban medical center.
Synopsis: Four hundred patients admitted with chest pain and an intermediate, pre-test probability of coronary artery disease were randomized to either CCTA or MPI. Patients were predominantly female, were ethnically varied, and had a mean age of 57 years.
Study results showed no significant difference in rates of cardiac catheterization that did not lead to revascularization at one-year follow-up. Specifically, 7.5% of patients in the CCTA group underwent catheterization not leading to revascularization, compared to 10% in the MPI group.
One limitation of the study is that it was conducted at a single site. Furthermore, the decision to proceed to catheterization was made clinically and not based on a predefined algorithm.
Bottom line: CCTA and MPI are both acceptable choices to determine the need for invasive testing in patients admitted with chest pain.
Citation: Levsky JM, Spevack DM, Travin MI, et al. Coronary computed tomography angiography versus radionuclide myocardial perfusion imaging in patients with chest pain admitted to telemetry: a randomized trial. Ann Intern Med. 2015;163(3):174-183.