Clinical Outcomes After Evaluation of Stable Chest Pain by Coronary Computed Tomographic Angiography Versus Usual Care

Abstract

Background— Limited data exist on how noninvasive testing options compare for evaluating patients with suspected stable coronary artery disease. In this study, we have performed a meta-analysis of randomized controlled trials comparing the use of coronary computed tomographic angiography (CTA) with usual care. Methods and Results— We systematically searched databases for randomized clinical trials comparing coronary CTA with usual care for the evaluation of stable chest pain with follow-up for cardiovascular outcomes. The primary outcomes were myocardial infarction and all-cause mortality. We identified 4 randomized clinical trials, including a total of 7403 patients undergoing coronary CTA and 7414 patients undergoing usual care with various functional testing approaches. When compared with usual care, the use of coronary CTA was associated with a significant reduction in the annual rate of myocardial infarction (rate ratio, 0.69; 95% confidence interval, 0.49–0.98; P =0.038), but no difference was found in all-cause mortality. There was a trend toward more invasive coronary angiographies among patients undergoing coronary CTA (odds ratio, 1.33; 95% confidence interval, 0.95–1.84; P =0.09) and higher use of coronary revascularizations (odds ratio, 1.77; 95% confidence interval, 1.14–2.75). Significant heterogeneity for invasive coronary angiography and revascularization was noted, which was attributable to the Scottish Computed Tomography of the HEART (SCOT-HEART) study. We found no difference in the rate of admission for cardiac chest pain (rate ratio, 1.21; 95% confidence interval, 0.95–1.54). Conclusions— In comparison to usual care, an initial investigation of suspected stable coronary artery disease using coronary CTA resulted in a significant reduction in myocardial infarction, an increased incidence of coronary revascularization, and no effect in all-cause mortality. Future studies should further define whether the potential reduction in myocardial infarction identified justifies the increased resource utilization associated with coronary CTA.

The STRATEGY Study (Stress Cardiac Magnetic Resonance Versus Computed Tomography Coronary Angiography for the Management of Symptomatic Revascularized Patients)

“…Our data could seem to contradict the conclusion of a recent meta-analysis published by Bittencourt et al, 28 showing that a cTCA strategy has a positive impact on major adverse cardiac events as compared with a functional strategy. However, our study population is completely different for several reasons that influence the prevalence of CAD and, therefore, the cost-effectiveness of an anatomic strategy versus a functional strategy.…”

“…First, our population is older than patients from the Bittencourt et al study. 28 Second, in this meta-analysis, the authors have included patients symptomatic for noncardiac chest pain as well with a CAD prevalence ranging between 11% and 64% while we have included only patients symptomatic for angina. Third, the functional strategy used in this meta-analysis was mainly based on SPECT for the PROMISE trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) and Min et al studies and exercise ECG for the CAPP trial (Cardiac CT for the Assessment of Chest Pain and Plaque) and SCOT HEART (Scottish Computed Tomography of the HEART Trial).…”

It’s in the Field of View!

“…It is the most robust predictor of cardiovascular events in both the asymptomatic and symptomatic populations and is associated with better accuracy and outcomes compared with functional testing. [4][5][6] In the absence of AD or PE, the relationship of presenting symptoms to coronary findings may be unclear and may be addressed by appropriate functional imaging confirmation.…”

Clinical Value of Coronary Computed Tomographic Angiography in Patients With Stable Angina

“…In this issue of Circulation: Cardiovascular Imaging, Bittencourt et al 8 performed a meta-analysis of all randomized controlled trials published until March 2015 that compared the clinical effectiveness of coronary CT angiography to other noninvasive strategies, and could make several interesting observations for which the separate trials had insufficient power. Although none of the trials demonstrated a statistically significant difference in hard end points, pooling of data from 14 817 patients in this meta-analysis demonstrated that implementation of cardiac CT was associated with a 31% lower myocardial infarction rate compared with usual care.…”