1. From a randomized trial of those with chest pain comparing coronary computed tomography angiography (CCTA) and myocardial perfusion imaging (MPI), there was no significant difference in the rate of revascularization.
2. There were no statistical differences between CCTA and MPI with regard to length of hospital stay, renal function, mortality, and cardiovascular events, but patients favored CCTA.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Chest pain suspicious for coronary artery disease is a common reason for emergency room visits and hospitalizations. Evaluation of chest pain can include noninvasive cardiac imaging such as coronary computed tomography angiography (CCTA) and radionuclide stress myocardial perfusion imaging (MPI). To determine if noninvasive cardiac imaging could identify patients who would benefit from revascularization and to avoid catheterization in others, this single-center randomized study examined patients with chest pain, who were randomized to receive either CCTA or MPI. The primary outcome was catheterization not leading to percutaneous or surgical revascularization within one year. The results indicated that there were no significant differences between CCTA and MPI with regard to the primary outcome, median length of stay in hospital, change in kidney function, all-cause mortality, and nonfatal major cardiovascular events, like heart attack. However, those who received CCTA, compared to MPI, received a lower dose of radiation and felt more favorably toward it. The main limitation of this study was its small size, which may have limited its power.
In-Depth [randomized controlled trial]: A total of 400 patients were 1:1 randomized to receive CCTA or MPI. The patients were mean age 57 years, 63% women, 95% ethnic minority and mean BMI of 31. Thirty (15%) CCTA patients and 32 (16%) MPI patients had 1 or more catheterization within one year (p = 0.89). Among these patients, 15 CCTA and 20 MPI patients did not have revascularization (p = 0.44). The median time to catheterization and revascularization for CCTA patients was 3.5 days (IQR 2 – 28.5) and 2 days (IQR 1.5 – 3.5), respectively. For MPI, median time to catheterization and revascularization was 2 days (IQR 1 – 5) and 1.5 days (IQR 1 – 4), respectively. From a subgroup with significantly abnormal findings on imaging, 5 of 20 (25%) CCTA and 16 of 31 (52%) MPI had catheterization that did not lead to revascularization (absolute difference -27%, 95%CI -50% to -3.9%, p = 0.083). The difference in median subjective patient rating score (1 being the highest out of 10) was insignificant (p = 0.149) for CCTA and MPI, however a significantly greater proportion of patients rated MPI negatively with score of 5 or worse (p = 0.001).
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