title: The STRATEGY Study (Stress Cardiac Magnetic Resonance Versus Computed Tomography Coronary Angiography for the Management of Symptomatic Revascularized Patients): Resources and Outcomes Impact.
abstract: BACKGROUND
  Computed tomography coronary angiography (cTCA) and stress cardiac magnetic resonance (stress-CMR) are suitable tools for diagnosing obstructive coronary artery disease in symptomatic patients with previous history of revascularization. However, performance appraisal of noninvasive tests must take in account the consequent diagnostic testing, invasive procedures, clinical outcomes, radiation exposure, and cumulative costs rather than their diagnostic accuracy only. We aimed to compare an anatomic (cTCA) versus a functional (stress-CMR) strategy in symptomatic patients with previous myocardial revascularization procedures.
  
  
  RESULTS
  Six hundred patients with chest pain and previous revascularization included in a prospective observational registry and evaluated by clinically indicated cTCA (n=300, mean age 68.2±9.7 years, male 255) or stress-CMR (n=300, mean age 67.6±9.7 years, male 263) were enrolled and followed-up in terms of subsequent noninvasive tests, invasive coronary angiography, revascularization procedures, cumulative effective radiation dose, major adverse cardiac events, defined as a composite end point of nonfatal myocardial infarction and cardiac death, and medical costs. The mean follow-up for cTCA and stress-CMR groups was similar (773.6±345 versus 752.8±291 days; P=0.21). Compared with stress-CMR, cTCA was associated with a higher rate of subsequent noninvasive tests (28% versus 17%; P=0.0009), invasive coronary angiography (31% versus 20%; P=0.0009), and revascularization procedures (24% versus 16%; P=0.007). Stress-CMR strategy was associated with a significant reduction of radiation exposure and cumulative costs (59% and 24%, respectively; P<0.001). Finally, patients undergoing stress-CMR showed a lower rate of major adverse cardiac events (5% versus 10%; P<0.010) and cost-effectiveness ratio (119.98±250.92 versus 218.12±298.45 Euro/y; P<0.001).
  
  
  CONCLUSIONS
  Compared with cTCA, stress-CMR is more cost-effective in symptomatic revascularized patients.
authors.affiliation: From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.). gianluca.pontone@ccfm.it.
authors.forename: Gianluca
authors.initials: G
authors.lastname: Pontone
authors.affiliation: From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.).
authors.forename: Daniele
authors.initials: D
authors.lastname: Andreini
authors.affiliation: From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.).
authors.forename: Andrea I
authors.initials: AI
authors.lastname: Guaricci
authors.affiliation: From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.).
authors.forename: Cristina
authors.initials: C
authors.lastname: Rota
authors.affiliation: From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.).
authors.forename: Marco
authors.initials: M
authors.lastname: Guglielmo
authors.affiliation: From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.).
authors.forename: Saima
authors.initials: S
authors.lastname: Mushtaq
authors.affiliation: From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.).
authors.forename: Andrea
authors.initials: A
authors.lastname: Baggiano
authors.affiliation: From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.).
authors.forename: Virginia
authors.initials: V
authors.lastname: Beltrama
authors.affiliation: From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.).
authors.forename: Laura
authors.initials: L
authors.lastname: Fusini
authors.affiliation: From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.).
authors.forename: Anna
authors.initials: A
authors.lastname: Solbiati
authors.affiliation: From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.).
authors.forename: Chiara
authors.initials: C
authors.lastname: Segurini
authors.affiliation: From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.).
authors.forename: Edoardo
authors.initials: E
authors.lastname: Conte
authors.affiliation: From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.).
authors.forename: Paola
authors.initials: P
authors.lastname: Gripari
authors.affiliation: From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.).
authors.forename: Andrea
authors.initials: A
authors.lastname: Annoni
authors.affiliation: From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.).
authors.forename: Alberto
authors.initials: A
authors.lastname: Formenti
authors.affiliation: From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.).
authors.forename: Maria
authors.initials: M
authors.lastname: Petulla'
authors.affiliation: From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.).
authors.forename: Federico
authors.initials: F
authors.lastname: Lombardi
authors.affiliation: From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.).
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Muscogiuri
authors.affiliation: From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.).
authors.forename: Antonio L
authors.initials: AL
authors.lastname: Bartorelli
authors.affiliation: From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.).
authors.forename: Mauro
authors.initials: M
authors.lastname: Pepi
mesh_terms: D000368:Aged; D002423:Cause of Death; D000072226:Computed Tomography Angiography / Q000191:economics; D017023:Coronary Angiography / Q000191:economics / Q000379:methods*; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000191:economics / Q000503:physiopathology / Q000628:therapy*; D003331:Coronary Vessels / Q000000981:diagnostic imaging* / Q000503:physiopathology; D003362:Cost-Benefit Analysis; D005260:Female; D017048:Health Care Costs; D006801:Humans; D007558:Italy; D008279:Magnetic Resonance Imaging / Q000191:economics / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology; D009204:Myocardial Revascularization / Q000009:adverse effects / Q000191:economics / Q000401:mortality; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011829:Radiation Dosage; D000069079:Radiation Exposure; D012042:Registries; D015203:Reproducibility of Results; D013997:Time Factors; D016896:Treatment Outcome; D014665:Vasodilator Agents / Q000008:administration & dosage* / Q000191:economics
chemical_list: D014665:Vasodilator Agents
keywords: computed tomography; coronary artery disease; cost; cost-effectiveness; magnetic resonance; outcome; radiation exposure; revascularization