Clinical question: Is it safe to perform computed tomography (CT) coronary angiography to rule out obstructive coronary artery disease (CAD) in patients with stable intermediate-risk chest pain instead of proceeding to invasive coronary angiography (ICA)?
Background: CT angiography identifies patients who are appropriate candidates for coronary revascularization. It is not clear if CT would safely replace ICA as an initial diagnostic imaging strategy for guiding the treatment of patients with stable chest pain.
Study design: Pragmatic, investigator-initiated, assessor-blinded, parallel-group, superiority trial
Setting: 26 certified clinical centers in 16 European countries with a median 3.5-year follow-up.
Synopsis: 3,561 patients with intermediate (10–60%) pretest probability of obstructive CAD who were referred to angiography centers were randomly assigned to invasive or CT angiography. Hemodialysis, arrhythmia, and pregnancy were exclusion criteria. Trial centers were given guidelines encouraging patients without obstructive CAD be discharged back to referring providers for further management.
Major adverse cardiac events occurred in 2.1% of the CT group and 3.0% of the ICA group (hazard ratio (HR) 0.7; 95% confidence interval (CI) 0.46-1.07). Major procedure-related complications occurred in 0.5% of patients in the CT group and 1.9% of patients in the ICA group (HR, 0.26; 95% CI, 0.13-0.55). Angina during the final four weeks of follow-up was similar between the groups. 22.3% of patients in the CT group underwent invasive angiography, 72.5% of whom were found to have obstructive CAD.
Bottom line: Using CT angiography to evaluate for obstructive CAD in patients with stable intermediate-risk chest pain is as safe as invasive angiography in preventing major adverse cardiac events over 3.5 years when performed at certified centers with qualified radiologists.
Citation: DISCHARGE trial group. CT or invasive coronary angiography in stable chest pain. N Engl J Med. 2022;28;386(17):1591-1602. doi:10.1056/NEJMoa2200963.
Dr. Mayer is an assistant professor of medicine at Saint Louis University School of Medicine, St. Louis, Mo.