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Functional Testing or Coronary Computed Tomography Angiography in Patients With Stable Coronary Artery Disease
Mads E Jørgensen1, Charlotte Andersson2, Bjarne L Nørgaard3
1Department of Health Research and Policy, Department of Medicine, Stanford University School of Medicine, Stanford, California; The Cardiovascular Research Center, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.
Insights
Coronary computed tomography angiography (CTA) led to more medication use and procedures for suspected coronary artery disease. However, CTA was linked to a lower risk of myocardial infarction (MI) but similar all-cause mortality compared to functional testing.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Health Outcomes Research
Background:
- The selection between anatomical (coronary computed tomography angiography - CTA) and functional noninvasive testing for suspected coronary artery disease (CAD) can influence patient management and outcomes.
- Evaluating the impact of initial noninvasive testing strategies on subsequent medical care and clinical results is crucial for optimizing CAD diagnosis and treatment.
Purpose of the Study:
- To analyze the association between initial noninvasive cardiac testing (coronary CTA vs. functional testing) and the subsequent use of medications, invasive procedures, and clinical outcomes in outpatients with stable symptoms.
- To compare the costs and long-term risks of mortality and myocardial infarction (MI) associated with coronary CTA versus functional testing.
Main Methods:
- A nationwide Danish register study included 86,705 outpatients with stable symptoms undergoing initial noninvasive cardiac testing (coronary CTA or functional testing) between 2009 and 2015.
- Subsequent use of noninvasive tests, invasive procedures, medications, and associated costs within 120 days were evaluated.
- Adjusted Cox proportional hazard models were used to analyze long-term risks of all-cause mortality and MI.
Main Results:
- Coronary CTA was associated with significantly higher use of statins (15.9% vs. 9.1%), aspirin (12.7% vs. 8.5%), invasive coronary angiography (14.7% vs. 10.1%), and percutaneous coronary intervention (3.8% vs. 2.1%) compared to functional testing (all p < 0.001).
- Mean costs were higher after coronary CTA ($995 vs. $718; p < 0.001).
- After adjustment, coronary CTA showed a comparable risk of all-cause mortality (HR: 0.96; 95% CI: 0.88-1.05) but a lower risk of MI (HR: 0.71; 95% CI: 0.61-0.82).
Conclusions:
- In stable patients with suspected CAD, coronary CTA use resulted in increased utilization of statins, aspirin, and invasive procedures, alongside higher healthcare costs compared to functional testing.
- Coronary CTA demonstrated a reduced risk of myocardial infarction (MI) but a similar risk of all-cause mortality relative to functional testing.
Background:
The choice of either anatomical or functional noninvasive testing to evaluate suspected coronary artery disease might affect subsequent clinical management and outcomes.
Objectives:
This study analyzed the association of initial noninvasive cardiac testing in outpatients with stable symptoms, with subsequent use of medications, invasive procedures, and clinical outcomes.
Methods:
We studied patients enrolled in a Danish nationwide register who underwent initial noninvasive cardiac testing with either coronary computed tomography angiography (CTA) or functional testing (exercise electrocardiography or nuclear stress testing) from 2009 to 2015. Further use of noninvasive testing, invasive procedures, medications, and medical costs within 120 days were evaluated. Risks of long-term mortality and myocardial infarction (MI) were analyzed using adjusted Cox proportional hazard models.
Results:
A total of 86,705 patients underwent either functional testing (n = 53,744, mean age 57.4 years, 49% males) or coronary CTA (n = 32,961, mean age 57.4 years, 45% males), and were followed for a median of 3.6 years. Compared with functional testing, there was significantly higher use of statins (15.9% vs. 9.1%), aspirin (12.7% vs. 8.5%), invasive coronary angiography (14.7% vs. 10.1%), and percutaneous coronary intervention (3.8% vs. 2.1%); all p < 0.001 after coronary CTA. The mean costs of subsequent testing, invasive procedures, and medications were higher after coronary CTA ($995 vs. $718; p < 0.001). Unadjusted rates of mortality (2.1% vs. 4.0%) and MI hospitalization (0.8% vs. 1.5%) were lower after coronary CTA than functional testing (both p < 0.001). After adjustment, coronary CTA was associated with a comparable all-cause mortality (hazard ratio: 0.96; 95% confidence interval: 0.88 to 1.05), and a lower risk of MI (hazard ratio: 0.71; 95% confidence interval: 0.61 to 0.82).
Conclusions:
In stable patients undergoing initial evaluation for suspected coronary artery disease, coronary CTA was associated with greater use of statins, aspirin, and invasive procedures, and higher costs than functional testing. Coronary CTA was associated with a lower risk of MI, but a similar risk of all-cause mortality.