Among patients with chest pain, it is unclear if anatomic assessment of coronary obstruction or functional assessment with stress testing leads to better patient outcomes. In this randomized controlled trial of 10,003 symptomatic patients, individuals were randomly assigned in a 1:1 fashion to either anatomical testing with coronary CT angiography (CTA) or to functional testing by one of several different modalities (exercise ECG (10%), nuclear stress testing (67%) or stress echo (23%)).\u00a0 Instead of diagnostic accuracy, as is seen with most such studies, the trial was powered for clinical outcomes with a primary composite endpoint of death, myocardial infarction, hospitalization for unstable angina, or major procedural complication.\u00a0 The study patients were a mean age 61 years, 53% were women, and the mean pretest probability of coronary artery disease was 53\u00b121%.\u00a0 Over a median follow-up of 25 months, the rate of the primary-end point was similar in patients undergoing CTA (3.3%) and functional testing (3.0%) (HR, 1.04; 95% CI, 0.83 to 1.29; P=0.75).\u00a0 More patients in the CTA group underwent cardiac catheterization and there was greater radiation exposure in the CTA group (12.0 mSv vs. 10.1 mSv; P<0.001) with 32.6% of patients in the functional-testing group having no radiation exposure.<\/p>\n
Conclusions<\/strong><\/p>\n In patients presenting with chest pain who require diagnostic testing for coronary disease, an initial strategy of anatomic testing with CTA in comparison with a functional test does not lead to any appreciable improvement in patient outcomes.<\/p>\n