Outcomes of Anatomical versus Functional Testing for Coronary Artery Disease

In a trial involving 10,003 patients with suspected coronary artery disease, clinical outcomes at 2 years were not improved with an initial strategy of CT angiography, as compared with functional testing (exercise ECG, nuclear stress testing, or stress echocardiography). New-onset, stable chest pain...

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Vydané v:The New England journal of medicine Ročník 372; číslo 14; s. 1291 - 1300
Hlavní autori: Douglas, Pamela S, Hoffmann, Udo, Patel, Manesh R, Mark, Daniel B, Al-Khalidi, Hussein R, Cavanaugh, Brendan, Cole, Jason, Dolor, Rowena J, Fordyce, Christopher B, Huang, Megan, Khan, Muhammad Akram, Kosinski, Andrzej S, Krucoff, Mitchell W, Malhotra, Vinay, Picard, Michael H, Udelson, James E, Velazquez, Eric J, Yow, Eric, Cooper, Lawton S, Lee, Kerry L
Médium: Journal Article
Jazyk:English
Vydavateľské údaje: United States Massachusetts Medical Society 02.04.2015
Predmet:
Aged
Angina
Angina, Unstable - epidemiology
Angiography
Cardiac Catheterization
Cardiovascular disease
Catheterization
Chest Pain - etiology
Clinical trials
Computed tomography
Coronary Angiography - adverse effects
Coronary Angiography - methods
Coronary artery
Coronary Artery Disease - diagnosis
Diagnostic tests
Dyspnea
Echocardiography
Echocardiography, Stress - adverse effects
EKG
Electrocardiography
Exercise Test
Female
Follow-Up Studies
Heart diseases
Humans
Kaplan-Meier Estimate
Male
Medical diagnosis
Middle Aged
Mortality
Myocardial infarction
Myocardial Infarction - epidemiology
Pain
Respiration
Tomography, X-Ray Computed
ISSN:0028-4793, 1533-4406
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Abstract In a trial involving 10,003 patients with suspected coronary artery disease, clinical outcomes at 2 years were not improved with an initial strategy of CT angiography, as compared with functional testing (exercise ECG, nuclear stress testing, or stress echocardiography). New-onset, stable chest pain is a common clinical problem that results in approximately 4 million stress tests annually in the United States in ambulatory patients without diagnosed heart disease. 1 Despite advances in cardiac testing, there is scant information on health-related outcomes and little consensus about which noninvasive test is preferable. 2 – 4 As a result, current patterns of care have been questioned, including the testing of very-low-risk populations 5 and the catheterization of patients who do not have obstructive coronary artery disease (CAD). 6 – 8 The development of coronary computed tomographic angiography (CTA) and its application in this context has the potential to . . .
AbstractList BackgroundMany patients have symptoms suggestive of coronary artery disease (CAD) and are often evaluated with the use of diagnostic testing, although there are limited data from randomized trials to guide care.MethodsWe randomly assigned 10,003 symptomatic patients to a strategy of initial anatomical testing with the use of coronary computed tomographic angiography (CTA) or to functional testing (exercise electrocardiography, nuclear stress testing, or stress echocardiography). The composite primary end point was death, myocardial infarction, hospitalization for unstable angina, or major procedural complication. Secondary end points included invasive cardiac catheterization that did not show obstructive CAD and radiation exposure.ResultsThe mean age of the patients was 60.8±8.3 years, 52.7% were women, and 87.7% had chest pain or dyspnea on exertion. The mean pretest likelihood of obstructive CAD was 53.3±21.4%. Over a median follow-up period of 25 months, a primary end-point event occurred in 164 of 4996 patients in the CTA group (3.3%) and in 151 of 5007 (3.0%) in the functional-testing group (adjusted hazard ratio, 1.04; 95% confidence interval, 0.83 to 1.29; P=0.75). CTA was associated with fewer catheterizations showing no obstructive CAD than was functional testing (3.4% vs. 4.3%, P=0.02), although more patients in the CTA group underwent catheterization within 90 days after randomization (12.2% vs. 8.1%). The median cumulative radiation exposure per patient was lower in the CTA group than in the functional-testing group (10.0 mSv vs. 11.3 mSv), but 32.6% of the patients in the functional-testing group had no exposure, so the overall exposure was higher in the CTA group (mean, 12.0 mSv vs. 10.1 mSv; P<0.001).ConclusionsIn symptomatic patients with suspected CAD who required noninvasive testing, a strategy of initial CTA, as compared with functional testing, did not improve clinical outcomes over a median follow-up of 2 years. (Funded by the National Heart, Lung, and Blood Institute; PROMISE ClinicalTrials.gov number, NCT01174550.)
In a trial involving 10,003 patients with suspected coronary artery disease, clinical outcomes at 2 years were not improved with an initial strategy of CT angiography, as compared with functional testing (exercise ECG, nuclear stress testing, or stress echocardiography). New-onset, stable chest pain is a common clinical problem that results in approximately 4 million stress tests annually in the United States in ambulatory patients without diagnosed heart disease. 1 Despite advances in cardiac testing, there is scant information on health-related outcomes and little consensus about which noninvasive test is preferable. 2 – 4 As a result, current patterns of care have been questioned, including the testing of very-low-risk populations 5 and the catheterization of patients who do not have obstructive coronary artery disease (CAD). 6 – 8 The development of coronary computed tomographic angiography (CTA) and its application in this context has the potential to . . .
Many patients have symptoms suggestive of coronary artery disease (CAD) and are often evaluated with the use of diagnostic testing, although there are limited data from randomized trials to guide care. We randomly assigned 10,003 symptomatic patients to a strategy of initial anatomical testing with the use of coronary computed tomographic angiography (CTA) or to functional testing (exercise electrocardiography, nuclear stress testing, or stress echocardiography). The composite primary end point was death, myocardial infarction, hospitalization for unstable angina, or major procedural complication. Secondary end points included invasive cardiac catheterization that did not show obstructive CAD and radiation exposure. The mean age of the patients was 60.8±8.3 years, 52.7% were women, and 87.7% had chest pain or dyspnea on exertion. The mean pretest likelihood of obstructive CAD was 53.3±21.4%. Over a median follow-up period of 25 months, a primary end-point event occurred in 164 of 4996 patients in the CTA group (3.3%) and in 151 of 5007 (3.0%) in the functional-testing group (adjusted hazard ratio, 1.04; 95% confidence interval, 0.83 to 1.29; P=0.75). CTA was associated with fewer catheterizations showing no obstructive CAD than was functional testing (3.4% vs. 4.3%, P=0.02), although more patients in the CTA group underwent catheterization within 90 days after randomization (12.2% vs. 8.1%). The median cumulative radiation exposure per patient was lower in the CTA group than in the functional-testing group (10.0 mSv vs. 11.3 mSv), but 32.6% of the patients in the functional-testing group had no exposure, so the overall exposure was higher in the CTA group (mean, 12.0 mSv vs. 10.1 mSv; P<0.001). In symptomatic patients with suspected CAD who required noninvasive testing, a strategy of initial CTA, as compared with functional testing, did not improve clinical outcomes over a median follow-up of 2 years. (Funded by the National Heart, Lung, and Blood Institute; PROMISE ClinicalTrials.gov number, NCT01174550.).
Author Udelson, James E
Hoffmann, Udo
Lee, Kerry L
Malhotra, Vinay
Velazquez, Eric J
Dolor, Rowena J
Khan, Muhammad Akram
Picard, Michael H
Al-Khalidi, Hussein R
Mark, Daniel B
Huang, Megan
Kosinski, Andrzej S
Cole, Jason
Fordyce, Christopher B
Yow, Eric
Cooper, Lawton S
Douglas, Pamela S
Krucoff, Mitchell W
Patel, Manesh R
Cavanaugh, Brendan
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  organization: From the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (P.S.D., M.R.P., D.B.M., H.R.A.-K., R.J.D., C.B.F., M.H., A.S.K., M.W.K., E.J.V., E.Y., K.L.L.); Massachusetts General Hospital, Harvard Medical School (U.H., M.H.P.), and Tufts Medical Center, Tufts University School of Medicine (J.E.U.) — both in Boston; New Mexico Heart Institute, Albuquerque (B.C.); Cardiology Associates, Mobile, AL (J.C.); North Dallas Research Associates, Dallas (M.A.K.); Cardiac Study Group, Puyallup, WA (V.M.); and the National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
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  givenname: Lawton S
  surname: Cooper
  fullname: Cooper, Lawton S
  organization: From the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (P.S.D., M.R.P., D.B.M., H.R.A.-K., R.J.D., C.B.F., M.H., A.S.K., M.W.K., E.J.V., E.Y., K.L.L.); Massachusetts General Hospital, Harvard Medical School (U.H., M.H.P.), and Tufts Medical Center, Tufts University School of Medicine (J.E.U.) — both in Boston; New Mexico Heart Institute, Albuquerque (B.C.); Cardiology Associates, Mobile, AL (J.C.); North Dallas Research Associates, Dallas (M.A.K.); Cardiac Study Group, Puyallup, WA (V.M.); and the National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
– sequence: 20
  givenname: Kerry L
  surname: Lee
  fullname: Lee, Kerry L
  organization: From the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (P.S.D., M.R.P., D.B.M., H.R.A.-K., R.J.D., C.B.F., M.H., A.S.K., M.W.K., E.J.V., E.Y., K.L.L.); Massachusetts General Hospital, Harvard Medical School (U.H., M.H.P.), and Tufts Medical Center, Tufts University School of Medicine (J.E.U.) — both in Boston; New Mexico Heart Institute, Albuquerque (B.C.); Cardiology Associates, Mobile, AL (J.C.); North Dallas Research Associates, Dallas (M.A.K.); Cardiac Study Group, Puyallup, WA (V.M.); and the National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
BackLink https://www.ncbi.nlm.nih.gov/pubmed/25773919$$D View this record in MEDLINE/PubMed
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Schneider, Ricky
Pellikka, Patricia
Javier, Julian
Ariani, Kevin
Braun, Edward
Bramlet, Dean
McConnell, Michael
Abdul-Nour, Khaled
Loh, Irving
Teague, Shawn
Tannenbaum, Alan
Danciu, Sorin
Martin, Enrico
Sorrell, Vincent
Friedrich, Steven
Weiss, Robert
Barker, Barbara
Koganti, Devendra
Heath, John
Sullivan, Daniel
Hagley, Michael
Chang, Donald
Banerjee, Supratim
Jones, David
Mahenthiran, Jo
Foster, Gary
Abidov, Aiden
Shapiro, Patricia
Foucauld, Jean
Ciaramita, Jeffrey
Schmalfuss, Carsten
Johnson, Michael
Sotolongo, Carlos
Moloo, Jamaluddin
Yang, Clifford
Sallach, Susan
Kahn, Andrew
Guzman, Pablo
McLaurin, Mary
Champney, Kimberly
Karlsberg, Ronald
Schmidt, 2nd, William
Ghai, Akash
Martin, Arthur
Morss, Alexander
Ginete, Wilson
Budoff, Matthew
Lurie, Mark
Forman, Steven
Hinchman, David
Clark, Craig
Sigurdsson, Gardar
Carroll, William
Hines, Jerome
Shaikh, Saeed
Keller, Andrew
Rivard, Andrew
Cole, Jason
Carlos, Edward
Vorobiof, Gabriel
Trivedi, Dinker
Saba, Souheil
Treat, Stephen
Hsu, Joe
Meengs, Mark
Hearne, Steven
Frohwein, Stephen
Turner
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A complete list of investigators in the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) is provided in the Supplementary Appendix, available at NEJM.org.
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Snippet In a trial involving 10,003 patients with suspected coronary artery disease, clinical outcomes at 2 years were not improved with an initial strategy of CT...
Many patients have symptoms suggestive of coronary artery disease (CAD) and are often evaluated with the use of diagnostic testing, although there are limited...
BackgroundMany patients have symptoms suggestive of coronary artery disease (CAD) and are often evaluated with the use of diagnostic testing, although there...
BACKGROUNDMany patients have symptoms suggestive of coronary artery disease (CAD) and are often evaluated with the use of diagnostic testing, although there...
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StartPage 1291
SubjectTerms Aged
Angina
Angina, Unstable - epidemiology
Angiography
Cardiac Catheterization
Cardiovascular disease
Catheterization
Chest Pain - etiology
Clinical trials
Computed tomography
Coronary Angiography - adverse effects
Coronary Angiography - methods
Coronary artery
Coronary Artery Disease - diagnosis
Diagnostic tests
Dyspnea
Echocardiography
Echocardiography, Stress - adverse effects
EKG
Electrocardiography
Exercise Test
Female
Follow-Up Studies
Heart diseases
Humans
Kaplan-Meier Estimate
Male
Medical diagnosis
Middle Aged
Mortality
Myocardial infarction
Myocardial Infarction - epidemiology
Pain
Respiration
Tomography, X-Ray Computed
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