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Published on: August 28, 2018
CT or Invasive Coronary Angiography in Stable Chest Pain
, Pál Maurovich-Horvat1, Maria Bosserdt1
1The authors' affiliations are as follows: the Heart and Vascular Center (P.M.-H., B.M., B.S., Z.D.D., M. Boussoussou) and the Department of Radiology, Medical Imaging Center (P.M.-H.), Semmelweis University, Budapest, Hungary; the Departments of Radiology (M. Bosserdt, E.Z., A.E.N., R. Haase, S.F., M. Rief, V.W., M.E., M.D.) and Cardiology and Angiology (M.L., H.D.), the Institute of Public Health (N.R., J.M.-N.), and the Institute of Biometry and Clinical Epidemiology (K.N.), Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin and DZHK (German Center for Cardiovascular Research) Partner Site Berlin (H.D., M.D.), Berlin Institute of Health and Berlin University Alliance (M.D.), Berlin, the Departments of Radiology (M.G.) and Cardiology (M.W.), University of Leipzig Heart Center, Leipzig, the Department of Cardiology, Alb Fils Kliniken, Göppingen (S.S., T.D.), the Bavarian Cancer Registry, Bavarian Health and Food Safety Authority, Munich (J.M.-N.), and the Department of Clinical Epidemiology and Applied Biostatistics, Universitätsklinikum Tübingen, Tübingen (L.M.S.-H., P.M.) - all in Germany; the Departments of Cardiology (K.F.K., A.D.K., T.E.) and Radiology (K.F.K., A.D.K.), Rigshospitalet, and the Department of Clinical Medicine, Faculty of Health and Medical Sciences (K.F.K., A.D.K., T.E., L.L., B.J.), and the Department of Public Health, Section for Health Services Research (K.S.H.), University of Copenhagen, Copenhagen, the Department of Cardiology, Herlev-Gentofte Hospital, Hellerup (L.L.), and the Department of Cardiology, Nordsjaellands Hospital, Hillerod (B.J.) - all in Denmark; the Department of Internal Medicine, Clinic of Cardiology (T.B., R. Hodas), and the Department of Radiology and Medical Imaging (M. Ratiu), George Emil Palade University of Medicine, Pharmacy, Science, and Technology, County Clinical Emergency Hospital Targu Mures (T.B.), and the Center of Advanced Research in Multimodality Cardiac Imaging, CardioMed Medical Center (I.B., I.R.) - all in Targu Mures, Romania; the Department of Cardiology, Southeastern Health and Social Care Trust, Belfast (P.D., C.O., S.K., S.R.), the Departments of Cardiology (G.D.) and Radiology (E.T.), Aintree University Hospital, the Department of Cardiology, Royal Liverpool University Hospital and the Institute for Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital (B.R., M. Fisher), and the Faculty of Health and Life Sciences, University of Liverpool (M. Fisher), Liverpool, Edge Hill University, Ormskirk (G.D.), the Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow (C.B., C.D.), and Golden Jubilee National Hospital, Clydebank (C.B.) - all in the United Kingdom; the Departments of Cardiology (J.R.-P., F.X.V., B.G.B.) and Radiology (H.C.C.), Hospital Universitario Vall d'Hebron, Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Centro de Investigación Biomédica en Red, Madrid (J.R.-P., F.X.V., B.G.B.), the Departments of Cardiology (I.D., A.R.) and Radiology (I.L.), Basurto Hospital, Bilbao, Basque Foundation for Health Innovation and Research, Barakaldo, and the Basque Office for Health Technology Assessment, Vitoria-Gasteiz (I.G.-I.) - all in Spain; the Departments of Cardiology (A.E.) and Radiology (L. Zvaigzne), Paul Stradins Clinical University Hospital, and the University of Latvia (A.E.) - both in Riga, Latvia; the Departments of Cardiology (C.Š.) and Imaging Methods (V.S.), Motol University Hospital, Prague, Czech Republic; the Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, and the Department of Cardiology, Hospital of Lithuanian University of Health Sciences (G.Š., L. Zajančkauskiene) - both in Kaunas, Lithuania; the Faculty of Medicine, University of Novi Sad, and the Department of Cardiology, Institute for Cardiovascular Diseases of Vojvodina, Novi Sad (N.Č.A., F.A.), and the Department of Cardiology, Internal Medicine Clinic, Clinical Hospital Center Zemun, and the Faculty of Medicine, University of Belgrade, Belgrade (R.V., A.N.N.) - all in Serbia; the Departments of Radiology (J.D.D.) and Cardiology (M.H.), St. Vincent's University Hospital and School of Medicine, University College Dublin (J.D.D.), Dublin; the National Institute of Cardiology, Warsaw (C. Kępka, M.K.), and the Departments of Cardiology (M.I.-S.) and Radiology (D.K.), Provincial Specialist Hospital in Wroclaw, Wroclaw - both in Poland; the Department of Clinical Internal, Anesthesiologic, and Cardiovascular Sciences, Sapienza University of Rome, Rome (M.M.), the Department of Biomedical Sciences, Humanitas University, and IRCCS Humanitas Research Hospital (M. Francone), Milan, and the Department of Radiology, University of Cagliari (L.S.), and the Department of Radiology, Azienda Ospedaliera Brotzu (G.M.), Cagliari - all in Italy; the Department of Internal Medicine III, the Department of Cardiology (F.P.), and the Department of Radiology (G.F.), Innsbruck Medical University, Innsbruck, Austria; the Turku PET Center (J.K.) and Heart Center (M.P.), Turku University Hospital and University of Turku, and the Administrative Center, Health Care District of Southwestern Finland (M.P.) - all in Turku, Finland; the Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal (R.F., V.G.R.); and the European Clinical Research Infrastructure Network-European Research Infrastructure Consortium, Paris (C. Kubiak).
Computed tomography (CT) and invasive coronary angiography (ICA) showed similar effectiveness for major adverse cardiovascular events in stable chest pain patients. However, CT significantly reduced procedure-related complications, offering a safer initial diagnostic strategy.
Area of Science:
- Cardiology
- Medical Imaging
- Clinical Trials
Background:
- Coronary artery disease (CAD) diagnosis often involves invasive coronary angiography (ICA).
- Computed tomography (CT) offers a noninvasive alternative for diagnosing obstructive CAD.
- The comparative effectiveness of CT versus ICA in managing CAD and reducing major adverse cardiovascular events (MACE) requires further investigation.
Purpose of the Study:
- To compare the effectiveness of CT and ICA as initial diagnostic strategies for patients with stable chest pain and intermediate pretest probability of obstructive CAD.
- To evaluate the impact of CT versus ICA on major adverse cardiovascular events (MACE) and procedure-related complications.
Main Methods:
- A pragmatic, randomized trial was conducted across 26 European centers.
- 3561 patients with stable chest pain and intermediate pretest probability of obstructive CAD were randomized to either CT or ICA as the initial diagnostic strategy.
- The primary outcome was MACE (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) over 3.5 years. Secondary outcomes included procedure-related complications and angina.
Main Results:
- No significant difference in MACE was observed between the CT group (2.1%) and the ICA group (3.0%) (hazard ratio, 0.70; 95% CI, 0.46 to 1.07).
- Major procedure-related complications were significantly lower in the CT group (0.5%) compared to the ICA group (1.9%) (hazard ratio, 0.26; 95% CI, 0.13 to 0.55).
- Angina rates were similar between the two groups.
Conclusions:
- For patients with stable chest pain and intermediate pretest CAD probability, an initial CT strategy yields similar rates of MACE compared to ICA.
- An initial CT strategy is associated with a lower frequency of major procedure-related complications.
- CT represents a safer initial diagnostic approach for selected patients with suspected coronary artery disease.
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