CT or Invasive Coronary Angiography in Stable Chest Pain
: DISCHARGE Trial Group; Maurovich-Horvat Pál, Bosserdt Maria, Kofoed Klaus F., Rieckmann Nina, Benedek Theodora, Donnelly Patrick, Rodriguez-Palomares José, Erglis Andrejs, Štěchovský Cyril, Šakalyte Gintare, Adić Nada Čemerlić, Gutberlet Matthias, Dodd Jonathan D., Diez Ignacio, Davis Gershan, Zimmermann Elke, Kępka Cezary, Vidakovic Radosav, Francone Marco, Ilnicka-Suckiel Małgorzata, Plank Fabian, Knuuti Juhani, Faria Rita, Schröder Stephen, Berry Colin, Saba Luca, Ruzsics Balazs, Kubiak Christine, Gutierrez-Ibarluzea Iñaki, Hansen Kristian Schultz, Müller-Nordhorn Jacqueline, Merkely Bela, Knudsen Andreas D., Benedek Imre, Orr Clare, Valente Filipa Xavier, Zvaigzne Ligita, Suchánek Vojtěch, Zajančkauskiene Laura, Adić Filip, Woinke Michael, Hensey Mark, Lecumberri Iñigo, Thwaite Erica, Laule Michael, Kruk Mariusz, Neskovic Aleksandar N., Mancone Massimo, Kuśmierz Donata, Feuchtner Gudrun, Pietilä Mikko, Ribeiro Vasco Gama, Drosch Tanja, Delles Christian, Matta Gildo, Fisher Michael, Szilveszter Bálint, Larsen Linnea, Ratiu Mihaela, Kelly Stephanie, del Blanco Bruno Garcia, Rubio Ainhoa, Drobni Zsófia D., Jurlander Birgit, Rodean Ioana, Regan Susan, Calabria Hug Cuéllar, Boussoussou Melinda, Engstrøm Thomas, Hodas Roxana, Napp Adriane E., Haase Robert, Feger Sarah, Serna-Higuita Lina M., Neumann Konrad, Dreger Henryk, Rief Matthias, Wieske Viktoria, Estrella Melanie, Martus Peter, Dewey Marc
Publisher: Massachusetts Medical Society
: 2022
: New England Journal of Medicine
: NEW ENGLAND JOURNAL OF MEDICINE
: NEW ENGL J MED
: 386
: 17
: 1591
: 1602
: 12
: 0028-4793
: 1533-4406
DOI: https://doi.org/10.1056/NEJMoa2200963
: https://www.nejm.org/doi/full/10.1056/NEJMoa2200963
Background: In the diagnosis of obstructive coronary artery disease (CAD), computed tomography (CT) is an accurate, noninvasive alternative to invasive coronary angiography (ICA). However, the comparative effectiveness of CT and ICA in the management of CAD to reduce the frequency of major adverse cardiovascular events is uncertain.
Methods: We conducted a pragmatic, randomized trial comparing CT with ICA as initial diagnostic imaging strategies for guiding the treatment of patients with stable chest pain who had an intermediate pretest probability of obstructive CAD and were referred for ICA at one of 26 European centers. The primary outcome was major adverse cardiovascular events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) over 3.5 years. Key secondary outcomes were procedure-related complications and angina pectoris.
Results: Among 3561 patients (56.2% of whom were women), follow-up was complete for 3523 (98.9%). Major adverse cardiovascular events occurred in 38 of 1808 patients (2.1%) in the CT group and in 52 of 1753 (3.0%) in the ICA group (hazard ratio, 0.70; 95% confidence interval [CI], 0.46 to 1.07; P = 0.10). Major procedure-related complications occurred in 9 patients (0.5%) in the CT group and in 33 (1.9%) in the ICA group (hazard ratio, 0.26; 95% CI, 0.13 to 0.55). Angina during the final 4 weeks of follow-up was reported in 8.8% of the patients in the CT group and in 7.5% of those in the ICA group (odds ratio, 1.17; 95% CI, 0.92 to 1.48).
Conclusions: Among patients referred for ICA because of stable chest pain and intermediate pretest probability of CAD, the risk of major adverse cardiovascular events was similar in the CT group and the ICA group. The frequency of major procedure-related complications was lower with an initial CT strategy.
