Sex Differences in the Performance of Cardiac Computed Tomography Compared With Functional Testing in Evaluating Stable Chest Pain: Subanalysis of the Multicenter, Randomized CRESCENT Trial (Calcium Imaging and Selective CT Angiography in Comparison to Functional Testing for Suspected Coronary Artery Disease).
BACKGROUND
Cardiac computed tomography (CT) represents an alternative diagnostic strategy for women with suspected coronary artery disease, with potential benefits in terms of effectiveness and cost-efficiency.


RESULTS
The CRESCENT trial (Calcium Imaging and Selective CT Angiography in Comparison to Functional Testing for Suspected Coronary Artery Disease) prospectively randomized 350 patients with stable angina (55% women; aged 55±10 years), mostly with an intermediate coronary artery disease probability, between cardiac CT and functional testing. The tiered cardiac CT protocol included a calcium scan followed by CT angiography if the Agatston calcium score was between 1 and 400. Patients with test-specific contraindications were not excluded from study participation. Sex differences were studied as a prespecified subanalysis. Enrolled women presented more frequently with atypical chest pain and had a lower pretest probability of coronary artery disease compared with men. Independently of these differences, cardiac CT led in both sexes to a fast final diagnosis when compared with functional testing, although the effect was larger in women (P interaction=0.01). The reduced need for further testing after CT, compared with functional testing, was most evident in women (P interaction=0.009). However, no sex interaction was observed with respect to changes in angina and quality of life, cumulative diagnostic costs, and applied radiation dose (all P interactions≥0.097).


CONCLUSIONS
Cardiac CT is more efficient in women than in men in terms of time to reach the final diagnosis and downstream testing. However, overall clinical outcome showed no significant difference between women and men after 1 year.


BACKGROUND
URL: http://www.clinicaltrials.gov. Unique identifier: NCT01393028.
From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and Stanford Cardiovascular Institute, Stanford University, CA (K.N.). m.m.lubbers@erasmusmc.nl.
Marisa
M
Lubbers
From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and Stanford Cardiovascular Institute, Stanford University, CA (K.N.).
Adriaan
A
Coenen
From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and Stanford Cardiovascular Institute, Stanford University, CA (K.N.).
Tobias
T
Bruning
From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and Stanford Cardiovascular Institute, Stanford University, CA (K.N.).
Tjebbe
T
Galema
From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and Stanford Cardiovascular Institute, Stanford University, CA (K.N.).
Jurgen
J
Akkerhuis
From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and Stanford Cardiovascular Institute, Stanford University, CA (K.N.).
Boudewijn
B
Krenning
From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and Stanford Cardiovascular Institute, Stanford University, CA (K.N.).
Paul
P
Musters
From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and Stanford Cardiovascular Institute, Stanford University, CA (K.N.).
Mohamed
M
Ouhlous
From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and Stanford Cardiovascular Institute, Stanford University, CA (K.N.).
Ahno
A
Liem
From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and Stanford Cardiovascular Institute, Stanford University, CA (K.N.).
Andre
A
Niezen
From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and Stanford Cardiovascular Institute, Stanford University, CA (K.N.).
Admir
A
Dedic
From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and Stanford Cardiovascular Institute, Stanford University, CA (K.N.).
Ron
R
van Domburg
From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and Stanford Cardiovascular Institute, Stanford University, CA (K.N.).
Miriam
M
Hunink
From the Department of Cardiology (M.L., A.C., T.G., P.M., A.D., R.v.D., K.N.) and Department of Radiology (M.L., A.C., M.O., A.D., M.H., K.N.), Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology (T.B.) and Department of Radiology (A.N.), Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands (J.A., A.L.); Department of Cardiology, Haven Hospital, Rotterdam, The Netherlands (B.K.); and Stanford Cardiovascular Institute, Stanford University, CA (K.N.).
Koen
K
Nieman
D000368:Aged; D060050:Angina, Stable / Q000209:etiology*; D000072226:Computed Tomography Angiography / Q000706:statistics & numerical data*; D017023:Coronary Angiography / Q000379:methods / Q000706:statistics & numerical data*; D003324:Coronary Artery Disease / Q000150:complications / Q000000981:diagnostic imaging*; D003331:Coronary Vessels / Q000000981:diagnostic imaging*; D018572:Disease-Free Survival; D005260:Female; D054625:Healthcare Disparities; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011829:Radiation Dosage; D000069079:Radiation Exposure; D015203:Reproducibility of Results; D012720:Severity of Illness Index; D012737:Sex Factors; D013997:Time Factors; D061205:Vascular Calcification / Q000150:complications / Q000000981:diagnostic imaging*
angiography; chest pain; clinical trial; coronary artery disease; women