Functional or Anatomic Testing for Patients with Stable Chest Pain?

Kirsten E. Fleischmann, MD, MPH reviewing Douglas PS et al. N Engl J Med 2015 Mar 14. Kramer CM. N Engl J Med 2015 Mar 14.

In this randomized study, researchers found no significant outcome differences between strategies.

Functional (i.e., stress) or anatomic (i.e., coronary computed tomographic angiography [CTA]) testing is used commonly to investigate new-onset chest pain, but which strategy leads to better outcomes? Investigators randomized 10,000 stable patients (mean age, 61; average estimated pretest probability of coronary artery disease [CAD], 53%) with suspected CAD to a strategy of initial testing with either CTA or functional testing. Functional-test choice was at the discretion of the treatment team: 67% of patients underwent nuclear stress imaging, 22% underwent stress echocardiography, and 10% underwent stress electrocardiography.

After a mean 25-month follow-up, the primary endpoint (death, myocardial infarction, hospitalization for unstable angina, or major procedural complication) had occurred in 3.3% of the CTA group and 3.0% of the functional-testing group, a nonsignificant difference. More patients in the CTA group underwent invasive angiography (12.2% vs. 8.1%) and revascularization (6.2% vs. 3.2%), but CTA was associated with significantly fewer catheterizations that showed no obstructive CAD (3.4% vs. 4.3%). Average radiation exposure was significantly lower in the functional-testing group (10.1 millisieverts vs. 12.0 mSv), because 33% of functional-testing patients had no radiation exposure. In those slated for nuclear stress tests, average radiation exposure was lower in the CTA group.

Citation(s):

Douglas PS et al. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med 2015 Mar 14; [e-pub].

Kramer CM.Cardiovascular imaging and outcomes — PROMISEs to keep. N Engl J Med 2015 Mar 14; [e-pub].