Chest pain concerning for a coronary syndrome leads to millions of hospital admissions each year that is often evaluated with diagnostic testing.  As a noninvasive diagnostic study, coronary computed tomography angiography (CCTA) has been shown to have excellent diagnostic capabilities.  However, concerns over CCTA remain, including radiation exposure, false-positives, and trials of the diagnostic modality that were mostly limited to low-risk patients with underrepresentation of minorities and women.  In this single-center randomized, controlled comparative effectiveness trial, 400 intermediate-risk patients (63% women, 54% Hispanic, 37% African-American) admitted to a telemetry floor were randomized to either CCTA or myocardial perfusion imaging (MPI) and followed for 40 months.  Patients with baseline renal dysfunction were excluded.  At 1 year, there were no significant differences in the primary outcome of coronary angiography that did not lead to revascularization (hazard ratio [HR], 0.77; 95% confidence interval [CI] 0.40-1.49; P = 0.44) or secondary outcomes that included length of stay, resource utilization, and patient experience.  All-cause radiation exposure was lower in the CCTA group (24 vs 29 millisieverts, P <0.0001) and more CCTA patients graded their experience favorably (P = 0.001).  Ten of 200 patients in the coronary CTA group were found to have non-cardiac diagnoses leading to chest pain (3 surgical), whereas no non-cardiac causes were found in the MPI group.  

Conclusion: In a diverse group of intermediate-risk patients admitted with chest pain, this study found no significant differences between CCTA and MPI for rates of subsequent angiography without revascularization or resource utilization.  In the evaluation of patients with chest pain, whether any imaging is warranted rather than exercise stress testing alone remains a pertinent question given the radiation exposure and costs associated with both CCTA and MPI.

Summarized by Jennifer L. Jarvie and Steven M. Bradley

Levsky JM, Spevack DM, Travini MI, Menegus, MA, Huang PW, Clark ET, Kim C, Hirschborn E, Freeman KD, Tobin JN, Haramati LB.  Coronary Computed Tomography Angiography Versus Radionuclide Myocardial Perfusion Imaging in Patients With Chest Pain Admitted to Telemetry: A Randomized Trial.  Ann Intern Med 2015;163:174-183.