title: Clinical Outcomes After Evaluation of Stable Chest Pain by Coronary Computed Tomographic Angiography Versus Usual Care: A Meta-Analysis.
abstract: BACKGROUND
  Limited data exist on how noninvasive testing options compare for evaluating patients with suspected stable coronary artery disease. In this study, we have performed a meta-analysis of randomized controlled trials comparing the use of coronary computed tomographic angiography (CTA) with usual care.
  
  
  RESULTS
  We systematically searched databases for randomized clinical trials comparing coronary CTA with usual care for the evaluation of stable chest pain with follow-up for cardiovascular outcomes. The primary outcomes were myocardial infarction and all-cause mortality. We identified 4 randomized clinical trials, including a total of 7403 patients undergoing coronary CTA and 7414 patients undergoing usual care with various functional testing approaches. When compared with usual care, the use of coronary CTA was associated with a significant reduction in the annual rate of myocardial infarction (rate ratio, 0.69; 95% confidence interval, 0.49-0.98; P=0.038), but no difference was found in all-cause mortality. There was a trend toward more invasive coronary angiographies among patients undergoing coronary CTA (odds ratio, 1.33; 95% confidence interval, 0.95-1.84; P=0.09) and higher use of coronary revascularizations (odds ratio, 1.77; 95% confidence interval, 1.14-2.75). Significant heterogeneity for invasive coronary angiography and revascularization was noted, which was attributable to the Scottish Computed Tomography of the HEART (SCOT-HEART) study. We found no difference in the rate of admission for cardiac chest pain (rate ratio, 1.21; 95% confidence interval, 0.95-1.54).
  
  
  CONCLUSIONS
  In comparison to usual care, an initial investigation of suspected stable coronary artery disease using coronary CTA resulted in a significant reduction in myocardial infarction, an increased incidence of coronary revascularization, and no effect in all-cause mortality. Future studies should further define whether the potential reduction in myocardial infarction identified justifies the increased resource utilization associated with coronary CTA.
authors.affiliation: From the Center for Clinical and Epidemiological Research, University Hospital and State of São Paulo Cancer Institute (ICESP) (M.S.B.) and Heart Institute (C.E.R.), University of São Paulo, São Paulo, Brazil; Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil (M.S.B.); Department of Medicine (Cardiology Service), Walter Reed National Military Medical Center, Bethesda, MD (E.A.H.); Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor (V.L.M.); and Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.C., M.D.C., R.B.). msbittencourt@mail.harvard.edu.
authors.forename: Márcio Sommer
authors.initials: MS
authors.lastname: Bittencourt
authors.affiliation: From the Center for Clinical and Epidemiological Research, University Hospital and State of São Paulo Cancer Institute (ICESP) (M.S.B.) and Heart Institute (C.E.R.), University of São Paulo, São Paulo, Brazil; Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil (M.S.B.); Department of Medicine (Cardiology Service), Walter Reed National Military Medical Center, Bethesda, MD (E.A.H.); Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor (V.L.M.); and Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.C., M.D.C., R.B.).
authors.forename: Edward A
authors.initials: EA
authors.lastname: Hulten
authors.affiliation: From the Center for Clinical and Epidemiological Research, University Hospital and State of São Paulo Cancer Institute (ICESP) (M.S.B.) and Heart Institute (C.E.R.), University of São Paulo, São Paulo, Brazil; Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil (M.S.B.); Department of Medicine (Cardiology Service), Walter Reed National Military Medical Center, Bethesda, MD (E.A.H.); Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor (V.L.M.); and Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.C., M.D.C., R.B.).
authors.forename: Venkatesh L
authors.initials: VL
authors.lastname: Murthy
authors.affiliation: From the Center for Clinical and Epidemiological Research, University Hospital and State of São Paulo Cancer Institute (ICESP) (M.S.B.) and Heart Institute (C.E.R.), University of São Paulo, São Paulo, Brazil; Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil (M.S.B.); Department of Medicine (Cardiology Service), Walter Reed National Military Medical Center, Bethesda, MD (E.A.H.); Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor (V.L.M.); and Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.C., M.D.C., R.B.).
authors.forename: Michael
authors.initials: M
authors.lastname: Cheezum
authors.affiliation: From the Center for Clinical and Epidemiological Research, University Hospital and State of São Paulo Cancer Institute (ICESP) (M.S.B.) and Heart Institute (C.E.R.), University of São Paulo, São Paulo, Brazil; Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil (M.S.B.); Department of Medicine (Cardiology Service), Walter Reed National Military Medical Center, Bethesda, MD (E.A.H.); Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor (V.L.M.); and Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.C., M.D.C., R.B.).
authors.forename: Carlos E
authors.initials: CE
authors.lastname: Rochitte
authors.affiliation: From the Center for Clinical and Epidemiological Research, University Hospital and State of São Paulo Cancer Institute (ICESP) (M.S.B.) and Heart Institute (C.E.R.), University of São Paulo, São Paulo, Brazil; Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil (M.S.B.); Department of Medicine (Cardiology Service), Walter Reed National Military Medical Center, Bethesda, MD (E.A.H.); Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor (V.L.M.); and Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.C., M.D.C., R.B.).
authors.forename: Marcelo F
authors.initials: MF
authors.lastname: Di Carli
authors.affiliation: From the Center for Clinical and Epidemiological Research, University Hospital and State of São Paulo Cancer Institute (ICESP) (M.S.B.) and Heart Institute (C.E.R.), University of São Paulo, São Paulo, Brazil; Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil (M.S.B.); Department of Medicine (Cardiology Service), Walter Reed National Military Medical Center, Bethesda, MD (E.A.H.); Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor (V.L.M.); and Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.C., M.D.C., R.B.).
authors.forename: Ron
authors.initials: R
authors.lastname: Blankstein
mesh_terms: D002637:Chest Pain / Q000000981:diagnostic imaging* / Q000401:mortality; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging* / Q000401:mortality; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D014057:Tomography, X-Ray Computed
keywords: angina, stable; chest pain; coronary angiography; coronary artery disease; myocardial infarction