• Jeffrey M Levsky, Daniel M Spevack, Mark I Travin, Mark A Menegus, Paul W Huang, Elana T Clark, Choo-Won Kim, Esther Hirschhorn, Katherine D Freeman, Jonathan N Tobin, and Linda B Haramati.
• Ann. Intern. Med. 2015 Aug 4;163(3):174-83.

BackgroundThe role of coronary computed tomography angiography (CCTA) in the management of symptomatic patients suspected of having coronary artery disease is expanding. However, prospective intermediate-term outcomes are lacking.ObjectiveTo compare CCTA with conventional noninvasive testing.DesignRandomized, controlled comparative effectiveness trial. (ClinicalTrials.gov: NCT00705458).SettingTelemetry-monitored wards of an inner-city medical center.Patients400 patients with acute chest pain (mean age, 57 years); 63% women; 54% Hispanic and 37% African-American; and low socioeconomic status.InterventionCCTA or radionuclide stress myocardial perfusion imaging (MPI).MeasurementsThe primary outcome was cardiac catheterization not leading to revascularization within 1 year. Secondary outcomes included length of stay, resource utilization, and patient experience. Safety outcomes included death, major cardiovascular events, and radiation exposure.ResultsThirty (15%) patients who had CCTA and 32 (16%) who had MPI underwent cardiac catheterization within 1 year. Fifteen (7.5%) and 20 (10%) of these patients, respectively, did not undergo revascularization (difference, -2.5 percentage points [95% CI, -8.6 to 3.5 percentage points]; hazard ratio, 0.77 [CI, 0.40 to 1.49]; P = 0.44). Median length of stay was 28.9 hours for the CCTA group and 30.4 hours for the MPI group (P = 0.057). Median follow-up was 40.4 months. For the CCTA and MPI groups, the incidence of death (0.5% versus 3%; P = 0.12), nonfatal cardiovascular events (4.5% versus 4.5%), rehospitalization (43% versus 49%), emergency department visit (63% versus 58%), and outpatient cardiology visit (23% versus 21%) did not differ. Long-term, all-cause radiation exposure was lower for the CCTA group (24 versus 29 mSv; P < 0.001). More patients in the CCTA group graded their experience favorably (P = 0.001) and would undergo the examination again (P = 0.003).LimitationThis was a single-site study, and the primary outcome depended on clinical management decisions.ConclusionThe CCTA and MPI groups did not significantly differ in outcomes or resource utilization over 40 months. Compared with MPI, CCTA was associated with less radiation exposure and with a more positive patient experience.Primary Funding SourceAmerican Heart Association.

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