title: Evaluation of computed tomography in patients with atypical angina or chest pain clinically referred for invasive coronary angiography: randomised controlled trial.
abstract: OBJECTIVE
  To evaluate whether invasive coronary angiography or computed tomography (CT) should be performed in patients clinically referred for coronary angiography with an intermediate probability of coronary artery disease.
  
  
  METHODS
  Prospective randomised single centre trial.
  
  
  METHODS
  University hospital in Germany.
  
  
  METHODS
  340 patients with suspected coronary artery disease and a clinical indication for coronary angiography on the basis of atypical angina or chest pain.
  
  
  METHODS
  168 patients were randomised to CT and 172 to coronary angiography. After randomisation one patient declined CT and 10 patients declined coronary angiography, leaving 167 patients (88 women) and 162 patients (78 women) for analysis. Allocation could not be blinded, but blinded independent investigators assessed outcomes.
  
  
  METHODS
  The primary outcome measure was major procedural complications within 48 hours of the last procedure related to CT or angiography.
  
  
  RESULTS
  Cardiac CT reduced the need for coronary angiography from 100% to 14% (95% confidence interval 9% to 20%, P<0.001) and was associated with a significantly greater diagnostic yield from coronary angiography: 75% (53% to 90%) v 15% (10% to 22%), P<0.001. Major procedural complications were uncommon (0.3%) and similar across groups. Minor procedural complications were less common in the CT group than in the coronary angiography group: 3.6% (1% to 8%) v 10.5% (6% to 16%), P=0.014. CT shortened the median length of stay in the angiography group from 52.9 hours (interquartile range 49.5-76.4 hours) to 30.0 hours (3.5-77.3 hours, P<0.001). Overall median exposure to radiation was similar between the CT and angiography groups: 5.0 mSv (interquartile range 4.2-8.7 mSv) v 6.4 mSv (3.4-10.7 mSv), P=0.45. After a median follow-up of 3.3 years, major adverse cardiovascular events had occurred in seven of 167 patients in the CT group (4.2%) and six of 162 (3.7%) in the coronary angiography group (adjusted hazard ratio 0.90, 95% confidence interval 0.30 to 2.69, P=0.86). 79% of patients stated that they would prefer CT for subsequent testing. The study was conducted at a University hospital in Germany and thus the performance of CT may be different in routine clinical practice. The prevalence was lower than expected, resulting in an underpowered study for the predefined primary outcome.
  
  
  CONCLUSIONS
  CT increased the diagnostic yield and was a safe gatekeeper for coronary angiography with no increase in long term events. The length of stay was shortened by 22.9 hours with CT, and patients preferred non-invasive testing.Trial registration ClinicalTrials.gov NCT00844220.
authors: Charité-Universitätsmedizin Berlin, Humboldt-Universität and Freie Universität zu Berlin, Germany dewey@charite.de.
authors: Marc
authors: M
authors: Dewey
authors: Charité-Universitätsmedizin Berlin, Humboldt-Universität and Freie Universität zu Berlin, Germany.
authors: Matthias
authors: M
authors: Rief
authors: Institute for Clinical Epidemiology and Applied Biometry, Tübingen, Germany.
authors: Peter
authors: P
authors: Martus
authors: Charité-Universitätsmedizin Berlin, Humboldt-Universität and Freie Universität zu Berlin, Germany.
authors: Benjamin
authors: B
authors: Kendziora
authors: Charité-Universitätsmedizin Berlin, Humboldt-Universität and Freie Universität zu Berlin, Germany.
authors: Sarah
authors: S
authors: Feger
authors: Charité-Universitätsmedizin Berlin, Humboldt-Universität and Freie Universität zu Berlin, Germany.
authors: Henryk
authors: H
authors: Dreger
authors: Charité-Universitätsmedizin Berlin, Humboldt-Universität and Freie Universität zu Berlin, Germany.
authors: Sascha
authors: S
authors: Priem
authors: Charité-Universitätsmedizin Berlin, Humboldt-Universität and Freie Universität zu Berlin, Germany.
authors: Fabian
authors: F
authors: Knebel
authors: Charité-Universitätsmedizin Berlin, Humboldt-Universität and Freie Universität zu Berlin, Germany.
authors: Marko
authors: M
authors: Böhm
authors: Institute of Medical Statistics, Computer Sciences and Documentation, Jena, Germany.
authors: Peter
authors: P
authors: Schlattmann
authors: Charité-Universitätsmedizin Berlin, Humboldt-Universität and Freie Universität zu Berlin, Germany.
authors: Bernd
authors: B
authors: Hamm
authors: Charité-Universitätsmedizin Berlin, Humboldt-Universität and Freie Universität zu Berlin, Germany.
authors: Eva
authors: E
authors: Schönenberger
authors: Charité-Universitätsmedizin Berlin, Humboldt-Universität and Freie Universität zu Berlin, Germany.
authors: Michael
authors: M
authors: Laule
authors: Charité-Universitätsmedizin Berlin, Humboldt-Universität and Freie Universität zu Berlin, Germany.
authors: Elke
authors: E
authors: Zimmermann
mesh_terms: D000789:Angina, Unstable / Q000000981:diagnostic imaging*; D002637:Chest Pain / Q000000981:diagnostic imaging*; D017023:Coronary Angiography / Q000379:methods*; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging*; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D000069079:Radiation Exposure / Q000706:statistics & numerical data; D012017:Referral and Consultation; D014057:Tomography, X-Ray Computed