title: Outcomes of anatomical versus functional testing for coronary artery disease.
abstract: BACKGROUND
  Many patients have symptoms suggestive of coronary artery disease (CAD) and are often evaluated with the use of diagnostic testing, although there are limited data from randomized trials to guide care.
  
  
  METHODS
  We randomly assigned 10,003 symptomatic patients to a strategy of initial anatomical testing with the use of coronary computed tomographic angiography (CTA) or to functional testing (exercise electrocardiography, nuclear stress testing, or stress echocardiography). The composite primary end point was death, myocardial infarction, hospitalization for unstable angina, or major procedural complication. Secondary end points included invasive cardiac catheterization that did not show obstructive CAD and radiation exposure.
  
  
  RESULTS
  The mean age of the patients was 60.8±8.3 years, 52.7% were women, and 87.7% had chest pain or dyspnea on exertion. The mean pretest likelihood of obstructive CAD was 53.3±21.4%. Over a median follow-up period of 25 months, a primary end-point event occurred in 164 of 4996 patients in the CTA group (3.3%) and in 151 of 5007 (3.0%) in the functional-testing group (adjusted hazard ratio, 1.04; 95% confidence interval, 0.83 to 1.29; P=0.75). CTA was associated with fewer catheterizations showing no obstructive CAD than was functional testing (3.4% vs. 4.3%, P=0.02), although more patients in the CTA group underwent catheterization within 90 days after randomization (12.2% vs. 8.1%). The median cumulative radiation exposure per patient was lower in the CTA group than in the functional-testing group (10.0 mSv vs. 11.3 mSv), but 32.6% of the patients in the functional-testing group had no exposure, so the overall exposure was higher in the CTA group (mean, 12.0 mSv vs. 10.1 mSv; P<0.001).
  
  
  CONCLUSIONS
  In symptomatic patients with suspected CAD who required noninvasive testing, a strategy of initial CTA, as compared with functional testing, did not improve clinical outcomes over a median follow-up of 2 years. (Funded by the National Heart, Lung, and Blood Institute; PROMISE ClinicalTrials.gov number, NCT01174550.).
authors.affiliation: From the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (P.S.D., M.R.P., D.B.M., H.R.A.-K., R.J.D., C.B.F., M.H., A.S.K., M.W.K., E.J.V., E.Y., K.L.L.); Massachusetts General Hospital, Harvard Medical School (U.H., M.H.P.), and Tufts Medical Center, Tufts University School of Medicine (J.E.U.) - both in Boston; New Mexico Heart Institute, Albuquerque (B.C.); Cardiology Associates, Mobile, AL (J.C.); North Dallas Research Associates, Dallas (M.A.K.); Cardiac Study Group, Puyallup, WA (V.M.); and the National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.).
authors.forename: Pamela S
authors.initials: PS
authors.lastname: Douglas
authors.forename: Udo
authors.initials: U
authors.lastname: Hoffmann
authors.forename: Manesh R
authors.initials: MR
authors.lastname: Patel
authors.forename: Daniel B
authors.initials: DB
authors.lastname: Mark
authors.forename: Hussein R
authors.initials: HR
authors.lastname: Al-Khalidi
authors.forename: Brendan
authors.initials: B
authors.lastname: Cavanaugh
authors.forename: Jason
authors.initials: J
authors.lastname: Cole
authors.forename: Rowena J
authors.initials: RJ
authors.lastname: Dolor
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Fordyce
authors.forename: Megan
authors.initials: M
authors.lastname: Huang
authors.forename: Muhammad Akram
authors.initials: MA
authors.lastname: Khan
authors.forename: Andrzej S
authors.initials: AS
authors.lastname: Kosinski
authors.forename: Mitchell W
authors.initials: MW
authors.lastname: Krucoff
authors.forename: Vinay
authors.initials: V
authors.lastname: Malhotra
authors.forename: Michael H
authors.initials: MH
authors.lastname: Picard
authors.forename: James E
authors.initials: JE
authors.lastname: Udelson
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Velazquez
authors.forename: Eric
authors.initials: E
authors.lastname: Yow
authors.forename: Lawton S
authors.initials: LS
authors.lastname: Cooper
authors.forename: Kerry L
authors.initials: KL
authors.lastname: Lee
mesh_terms: D000368:Aged; D000789:Angina, Unstable / Q000453:epidemiology; D006328:Cardiac Catheterization; D002637:Chest Pain / Q000209:etiology; D017023:Coronary Angiography / Q000009:adverse effects / Q000379:methods; D003324:Coronary Artery Disease / Q000175:diagnosis*; D025401:Echocardiography, Stress / Q000009:adverse effects; D004562:Electrocardiography; D005080:Exercise Test; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009026:Mortality; D009203:Myocardial Infarction / Q000453:epidemiology; D014057:Tomography, X-Ray Computed