Clinical question: Is coronary computed tomography angiography better than stress testing for detecting coronary artery disease?
Bottom line: For the evaluation of chest pain in intermediate-risk patients, coronary computed tomography angiography (CCTA) is comparable with myocardial perfusion imaging (MPI) in its ability to select patients for invasive management. Both modalities are also similar when it comes to downstream resource use and adverse cardiovascular events. CCTA is associated with less radiation exposure (LOE = 1b).
Reference: 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. Ann Intern Med 2015;163(3):174-183.
Study design: Randomized controlled trial (nonblinded)
Funding source: Foundation
Setting: Inpatient (any location) with outpatient follow-up
The effectiveness of a noninvasive coronary imaging modality lies in its ability to identify patients who will need invasive management. In this study, intermediate-risk patients admitted to telemetry for the evaluation of chest pain who clinically required noninvasive imaging were randomized, using concealed allocation, to receive either CCTA or radionuclide stress MPI.
At baseline, the mean age in both groups was 57 years, two-thirds of the patients were female, and more than 90% were ethnic minorities. Analysis was by intention to treat. The primary outcome was the rate of cardiac catheterization that did not lead to revascularization within one year of the imaging test. There was no significant difference between the two groups for this outcome. However, in a subgroup analysis of patients with signficantly abnormal results on their imaging test, there was a nonsignificant trend toward fewer catheterizations without revascularization in the CCTA group (25% vs 52%; P=0.083).
For secondary outcomes, there were no differences detected between the two groups in length of stay, major adverse cardiovascular events, or downstream resource use, including rehospitalizations and further imaging. The CCTA group had less radiation exposure and reported a better patient experience.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.