Original Research
4 August 2015

Coronary Computed Tomography Angiography Versus Radionuclide Myocardial Perfusion Imaging in Patients With Chest Pain Admitted to Telemetry: A Randomized Trial

Publication: Annals of Internal Medicine
Volume 163, Number 3

Abstract

Background:

The 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.

Objective:

To compare CCTA with conventional noninvasive testing.

Design:

Randomized, controlled comparative effectiveness trial. (ClinicalTrials.gov: NCT00705458)

Setting:

Telemetry-monitored wards of an inner-city medical center.

Patients:

400 patients with acute chest pain (mean age, 57 years); 63% women; 54% Hispanic and 37% African-American; and low socioeconomic status.

Intervention:

CCTA or radionuclide stress myocardial perfusion imaging (MPI).

Measurements:

The 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.

Results:

Thirty (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).

Limitation:

This was a single-site study, and the primary outcome depended on clinical management decisions.

Conclusion:

The 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 Source:

American Heart Association.

Get full access to this article

View all available purchase options and get full access to this article.

References

1.
Nabel EGBraunwald E. A tale of coronary artery disease and myocardial infarction. N Engl J Med. 2012;366:54-63. [PMID: 22216842]  doi: 10.1056/NEJMra1112570
2.
Go ASMozaffarian DRoger VLBenjamin EJBerry JDBlaha MJet alAmerican Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation. 2014;129:e28-e292. [PMID: 24352519]  doi: 10.1161/01.cir.0000441139.02102.80
3.
Amsterdam EAKirk JDBluemke DADiercks DFarkouh MEGarvey JLet alAmerican Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Interdisciplinary Council on Quality of Care and Outcomes Research. Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. Circulation. 2010;122:1756-76. [PMID: 20660809]  doi: 10.1161/CIR.0b013e3181ec61df
4.
Hermann LKNewman DHPleasant WARojanasarntikul DLakoff DGoldberg SAet al. Yield of routine provocative cardiac testing among patients in an emergency department-based chest pain unit. JAMA Intern Med. 2013;173:1128-33. [PMID: 23689690]  doi: 10.1001/jamainternmed.2013.850
5.
Hlatky MADouglas PSCook NLWells BBenjamin EJDickersin Ket al. Future directions for cardiovascular disease comparative effectiveness research: report of a workshop sponsored by the National Heart, Lung, and Blood Institute. J Am Coll Cardiol. 2012;60:569-80. [PMID: 22796257]  doi: 10.1016/j.jacc.2011.12.057
6.
Budoff MJDowe DJollis JGGitter MSutherland JHalamert Eet al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol. 2008;52:1724-32. [PMID: 19007693]  doi: 10.1016/j.jacc.2008.07.031
7.
Miller JMRochitte CEDewey MArbab-Zadeh ANiinuma HGottlieb Iet al. Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med. 2008;359:2324-36. [PMID: 19038879]  doi: 10.1056/NEJMoa0806576
8.
Meijboom WBMeijs MFSchuijf JDCramer MJMollet NRvan Mieghem CAet al. Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol. 2008;52:2135-44. [PMID: 19095130]  doi: 10.1016/j.jacc.2008.08.058
9.
Min JKDunning ALin FYAchenbach SAl-Mallah MBudoff MJet alCONFIRM Investigators. Age- and sex-related differences in all-cause mortality risk based on coronary computed tomography angiography findings results from the International Multicenter CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry) of 23,854 patients without known coronary artery disease. J Am Coll Cardiol. 2011;58:849-60. [PMID: 21835321]  doi: 10.1016/j.jacc.2011.02.074
10.
Hulten EVillines TCCheezum MKBerman DSDunning AAchenbach Set alCONFIRM Investigators. Usefulness of coronary computed tomography angiography to predict mortality and myocardial infarction among Caucasian, African and East Asian ethnicities (from the CONFIRM [Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter] Registry). Am J Cardiol. 2013;111:479-85. [PMID: 23211358]  doi: 10.1016/j.amjcard.2012.10.028
11.
Hadamitzky MAchenbach SAl-Mallah MBerman DBudoff MCademartiri Fet alCONFIRM Investigators. Optimized prognostic score for coronary computed tomographic angiography: results from the CONFIRM registry (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter Registry). J Am Coll Cardiol. 2013;62:468-76. [PMID: 23727215]  doi: 10.1016/j.jacc.2013.04.064
12.
Shaw LJHausleiter JAchenbach SAl-Mallah MBerman DSBudoff MJet alCONFIRM Registry Investigators. Coronary computed tomographic angiography as a gatekeeper to invasive diagnostic and surgical procedures: results from the multicenter CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: an International Multicenter) registry. J Am Coll Cardiol. 2012;60:2103-14. [PMID: 23083780]  doi: 10.1016/j.jacc.2012.05.062
13.
Min JKBerman DSDunning AAchenbach SAl-Mallah MBudoff MJet al. All-cause mortality benefit of coronary revascularization vs. medical therapy in patients without known coronary artery disease undergoing coronary computed tomographic angiography: results from CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter Registry). Eur Heart J. 2012;33:3088-97. [PMID: 23048194]  doi: 10.1093/eurheartj/ehs315
14.
Goldstein JAGallagher MJO'Neill WWRoss MAO'Neil BJRaff GL. A randomized controlled trial of multi-slice coronary computed tomography for evaluation of acute chest pain. J Am Coll Cardiol. 2007;49:863-71. [PMID: 17320744]
15.
Goldstein JAChinnaiyan KMAbidov AAchenbach SBerman DSHayes SWet alCT-STAT Investigators. The CT-STAT (Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment) trial. J Am Coll Cardiol. 2011;58:1414-22. [PMID: 21939822]  doi: 10.1016/j.jacc.2011.03.068
16.
Litt HIGatsonis CSnyder BSingh HMiller CDEntrikin DWet al. CT angiography for safe discharge of patients with possible acute coronary syndromes. N Engl J Med. 2012;366:1393-403. [PMID: 22449295]  doi: 10.1056/NEJMoa1201163
17.
Hoffmann UTruong QASchoenfeld DAChou ETWoodard PKNagurney JTet alROMICAT-II Investigators. Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med. 2012;367:299-308. [PMID: 22830462]  doi: 10.1056/NEJMoa1201161
18.
Einstein AJHenzlova MJRajagopalan S. Estimating risk of cancer associated with radiation exposure from 64-slice computed tomography coronary angiography. JAMA. 2007;298:317-23. [PMID: 17635892]
19.
Shreibati JBBaker LCHlatky MA. Association of coronary CT angiography or stress testing with subsequent utilization and spending among Medicare beneficiaries. JAMA. 2011;306:2128-36. [PMID: 22089720]  doi: 10.1001/jama.2011.1652
20.
Hulten EPickett CBittencourt MSVillines TCPetrillo SDiCarli MFet al. Outcomes after coronary computed tomography angiography in the emergency department: a systematic review and meta-analysis of randomized, controlled trials. J Am Coll Cardiol. 2013;61:880-92. [PMID: 23395069]  doi: 10.1016/j.jacc.2012.11.061
21.
Meinert CL. The inclusion of women in clinical trials. Science. 1995;269:795-6. [PMID: 7638594]
22.
Harris DJDouglas PS. Enrollment of women in cardiovascular clinical trials funded by the National Heart, Lung, and Blood Institute. N Engl J Med. 2000;343:475-80. [PMID: 10944565]
23.
Zhang TTsang WWijeysundera HCKo DT. Reporting and representation of ethnic minorities in cardiovascular trials: a systematic review. Am Heart J. 2013;166:52-7. [PMID: 23816021]  doi: 10.1016/j.ahj.2013.03.022
24.
Hendel RCBerman DSDiCarli MFHeidenreich PAHenkin REPellikka PAet alAmerican College of Cardiology Foundation Appropriate Use Criteria Task Force. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. Circulation. 2009;119:e561-87. [PMID: 19451357]  doi: 10.1161/CIRCULATIONAHA.109.192519
25.
Levsky JMTravin MISpevack DMMenegus MAHuang PWGoldberg Yet al. Rationale and design of a randomized controlled trial comparing stress myocardial perfusion imaging with coronary CT angiography as the initial imaging study for intermediate-risk patients admitted with chest pain. J Cardiovasc Comput Tomogr. 2009;3:264-71. [PMID: 19577217]  doi: 10.1016/j.jcct.2009.05.006
26.
Anderson JLAdams CDAntman EMBridges CRCaliff RMCasey DE Jret alAmerican College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:e663-828. [PMID: 23630129]  doi: 10.1161/CIR.0b013e31828478ac
27.
Radiation Dose Assessment Resource (RADAR) Medical Procedure Radiation Dose Calculator. Accessed at www.doseinfo-radar.com/RADARDoseRiskCalc.html on 23 December 2014.
28.
X-Ray Risk. Accessed at www.xrayrisk.com on 23 December 2014.
29.
GraphPad Software QuickCalcs: Analyze a 2x2 contingency table. Accessed at www.graphpad.com/quickcalcs/contingency1/ on 9 March 2015.
30.
The confidence interval of a proportion. Accessed at http://vassarstats.net/prop1.html on 9 March 2015.
31.
Patel MRPeterson EDDai DBrennan JMRedberg RFAnderson HVet al. Low diagnostic yield of elective coronary angiography. N Engl J Med. 2010;362:886-95. [PMID: 20220183]  doi: 10.1056/NEJMoa0907272
32.
Douglas PSHoffmann UPatel MRMark DBAl-Khalidi HRCavanaugh Bet alPROMISE Investigators. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med. 2015;372:1291-300. [PMID: 25773919]  doi: 10.1056/NEJMoa1415516
33.
Duvall WLSavino JALevine EJBaber ULin JTEinstein AJet al. A comparison of coronary CTA and stress testing using high-efficiency SPECT MPI for the evaluation of chest pain in the emergency department. J Nucl Cardiol. 2014;21:305-18. [PMID: 24310280]  doi: 10.1007/s12350-013-9823-y
34.
Chen MYShanbhag SMArai AE. Submillisievert median radiation dose for coronary angiography with a second-generation 320-detector row CT scanner in 107 consecutive patients. Radiology. 2013;267:76-85. [PMID: 23340461]  doi: 10.1148/radiol.13122621
35.
Min JKLeipsic JPencina MJBerman DSKoo BKvan Mieghem Cet al. Diagnostic accuracy of fractional flow reserve from anatomic CT angiography. JAMA. 2012;308:1237-45. [PMID: 22922562]
36.
Rochitte CEGeorge RTChen MYArbab-Zadeh ADewey MMiller JMet al. Computed tomography angiography and perfusion to assess coronary artery stenosis causing perfusion defects by single photon emission computed tomography: the CORE320 study. Eur Heart J. 2014;35:1120-30. [PMID: 24255127]  doi: 10.1093/eurheartj/eht488
37.
Mc Ardle BADowsley TFdeKemp RAWells GABeanlands RS. Does rubidium-82 PET have superior accuracy to SPECT perfusion imaging for the diagnosis of obstructive coronary disease? A systematic review and meta-analysis. J Am Coll Cardiol. 2012;60:1828-37. [PMID: 23040573]  doi: 10.1016/j.jacc.2012.07.038
38.
Murthy VLNaya MFoster CRHainer JGaber MDi Carli Get al. Improved cardiac risk assessment with noninvasive measures of coronary flow reserve. Circulation. 2011;124:2215-24. [PMID: 22007073]  doi: 10.1161/CIRCULATIONAHA.111.050427

Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 163Number 34 August 2015
Pages: 174 - 183

History

Published online: 4 August 2015
Published in issue: 4 August 2015

Keywords

Authors

Affiliations

Jeffrey M. Levsky, MD, PhD
From Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.
Daniel M. Spevack, MD, MS
From Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.
Mark I. Travin, MD
From Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.
Mark A. Menegus, MD
From Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.
Paul W. Huang, MD
From Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.
Elana T. Clark, MD
From Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.
Choo-won Kim, MD
From Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.
Esther Hirschhorn, BS
From Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.
Katherine D. Freeman, DrPH
From Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.
Jonathan N. Tobin, PhD
From Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.
Linda B. Haramati, MD, MS
From Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.
Acknowledgment: The authors thank study coordinators Rizwan Aslam, Prameela Banoth, Shimon Farkas, Adina Haramati, Raphael Hulkower, David Kawior, Kristen Launier, Rikah Lerer, Shey Mukundan, Dieudonne Nonga, Paul O'Connor, Danny Nhan, Shayne Sebold, Samantha Selesny, Daniel Sova, Christian Stanton, and Shayna Vega. They thank Hannah Simons for help with statistical analyses and Nina Ackerman for help with analyzing socioeconomic status. They also acknowledge the contribution of the study's data and safety monitoring board members: Drs. Michael Farkouh, Gregory Pearson, Yungtai Lo, Michelle Johnson, and James Godbold.
Grant Support: By the American Heart Association Clinical Research Program (grant 0885024D) and the National Center for Advancing Translational Sciences (Clinical and Translational Science Award grants 1 UL1 TR001073-01), a component of the National Institutes of Health.
Disclosures: Dr. Travin reports a grant and other funds from GE Healthcare during the conduct of this study. Dr. Tobin reports receiving grants from National Institutes of Health, Agency for Healthcare Research and Quality, Patient-Centered Outcomes Research Institute, and Centers for Disease Control and Prevention during the conduct of the study. Dr. Levsky reports grants from American Heart Association during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOf InterestForms.do?msNum=M14-2948.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Reproducible Research Statement: Study protocol, data set, and statistical code: Available from Dr. Levsky (e-mail, [email protected]). Statistical code: Not applicable.
Corresponding Author: Jeffrey M. Levsky, MD, PhD, Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467-2490; e-mail, [email protected].
Current Author Addresses: Drs. Levsky and Haramati: Division of Cardiothoracic Imaging, Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467-2490.
Drs. Spevack and Menegus: Division of Cardiology, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467-2490.
Dr. Travin: Division of Nuclear Medicine, Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467-2490.
Dr. Huang: Division of Hospital Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467-2490.
Dr. Clark: Cohen Children's Medical Center, 269-01 76th Avenue, New Hyde Park, NY 11040.
Dr. Kim: Department of Radiology, Stony Brook School of Medicine, 100 Nicolls Road, HSC L4 Room 120, Stony Brook, NY 11794-8460.
Ms. Hirschhorn: 1925 Eastchester Road, Apartment 6A, Bronx, NY 10461.
Dr. Freeman: Extrapolate Statistics, 1145 Harbor Drive, Suite 1A, Delray Beach, FL 33483.
Dr. Tobin: Clinical Directors Network, 5 West 37th Street, 10th Floor, New York, NY 10018.
Author Contributions: Conception and design: J.M. Levsky, D.M. Spevack, M.I. Travin, K.D. Freeman, J.N. Tobin, L.B. Haramati.
Analysis and interpretation of the data: J.M. Levsky, D.M. Spevack, M.I. Travin, M.A. Menegus, E. Hirschhorn, K.D. Freeman, J.N. Tobin, L.B. Haramati.
Drafting of the article: J.M. Levsky, M.A. Menegus, J.N. Tobin, L.B. Haramati.
Critical revision for important intellectual content: J.M. Levsky, D.M. Spevack, M.I. Travin, M.A. Menegus, E.T. Clark, C. Kim, E. Hirschhorn, K.D. Freeman, J.N. Tobin, L.B. Haramati.
Final approval of the article: J.M. Levsky, D.M. Spevack, M.I. Travin, M.A. Menegus, E.T. Clark, C. Kim, E. Hirschhorn, J.N. Tobin, L.B. Haramati.
Provision of study materials or patients: M.I. Travin, L.B. Haramati.
Statistical expertise: J.M. Levsky, K.D. Freeman, J.N. Tobin.
Obtaining of funding: J.M. Levsky, J.N. Tobin.
Administrative, technical, or logistic support: D.M. Spevack, M.A. Menegus, E.T. Clark, J.N. Tobin. L.B. Haramati.
Collection and assembly of data: J.M. Levsky, E.T. Clark, C. Kim, E. Hirschhorn, J.N. Tobin, L.B. Haramati.
This article was published online first at www.annals.org on 9 June 2015.

Metrics & Citations

Metrics

Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. For an editable text file, please select Medlars format which will download as a .txt file. Simply select your manager software from the list below and click Download.

For more information or tips please see 'Downloading to a citation manager' in the Help menu.

Format





Download article citation data for:
Jeffrey M. Levsky, Daniel M. Spevack, Mark I. Travin, et al. Coronary Computed Tomography Angiography Versus Radionuclide Myocardial Perfusion Imaging in Patients With Chest Pain Admitted to Telemetry: A Randomized Trial. Ann Intern Med.2015;163:174-183. [Epub 4 August 2015]. doi:10.7326/M14-2948

View More

Get Access

Login Options:
Purchase

You will be redirected to acponline.org to sign-in to Annals to complete your purchase.

Create your Free Account

You will be redirected to acponline.org to create an account that will provide access to Annals.

View options

PDF/ePub

View PDF/ePub

Related in ACP Journals

Full Text

View Full Text

Media

Figures

Other

Tables

Share

Share

Copy the content Link

Share on social media