title: Functional Testing or Coronary Computed Tomography Angiography in Patients With Stable Coronary Artery Disease.
abstract: BACKGROUND
  The choice of either anatomical or functional noninvasive testing to evaluate suspected coronary artery disease might affect subsequent clinical management and outcomes.
  
  
  OBJECTIVE
  This study analyzed the association of initial noninvasive cardiac testing in outpatients with stable symptoms, with subsequent use of medications, invasive procedures, and clinical outcomes.
  
  
  METHODS
  We studied patients enrolled in a Danish nationwide register who underwent initial noninvasive cardiac testing with either coronary computed tomography angiography (CTA) or functional testing (exercise electrocardiography or nuclear stress testing) from 2009 to 2015. Further use of noninvasive testing, invasive procedures, medications, and medical costs within 120 days were evaluated. Risks of long-term mortality and myocardial infarction (MI) were analyzed using adjusted Cox proportional hazard models.
  
  
  RESULTS
  A total of 86,705 patients underwent either functional testing (n = 53,744, mean age 57.4 years, 49% males) or coronary CTA (n = 32,961, mean age 57.4 years, 45% males), and were followed for a median of 3.6 years. Compared with functional testing, there was significantly higher use of statins (15.9% vs. 9.1%), aspirin (12.7% vs. 8.5%), invasive coronary angiography (14.7% vs. 10.1%), and percutaneous coronary intervention (3.8% vs. 2.1%); all p < 0.001 after coronary CTA. The mean costs of subsequent testing, invasive procedures, and medications were higher after coronary CTA ($995 vs. $718; p < 0.001). Unadjusted rates of mortality (2.1% vs. 4.0%) and MI hospitalization (0.8% vs. 1.5%) were lower after coronary CTA than functional testing (both p < 0.001). After adjustment, coronary CTA was associated with a comparable all-cause mortality (hazard ratio: 0.96; 95% confidence interval: 0.88 to 1.05), and a lower risk of MI (hazard ratio: 0.71; 95% confidence interval: 0.61 to 0.82).
  
  
  CONCLUSIONS
  In stable patients undergoing initial evaluation for suspected coronary artery disease, coronary CTA was associated with greater use of statins, aspirin, and invasive procedures, and higher costs than functional testing. Coronary CTA was associated with a lower risk of MI, but a similar risk of all-cause mortality.
authors.affiliation: Department of Health Research and Policy, Department of Medicine, Stanford University School of Medicine, Stanford, California; The Cardiovascular Research Center, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark. Electronic address: Mads.Emil.Joergensen@regionh.dk.
authors.forename: Mads E
authors.initials: ME
authors.lastname: Jørgensen
authors.affiliation: The Cardiovascular Research Center, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark; Division of Cardiology, Department of Internal Medicine, Glostrup University Hospital, Glostrup, Denmark.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Andersson
authors.affiliation: Department of Cardiology, Aarhus University Hospital-Skejby, Aarhus, Denmark.
authors.forename: Bjarne L
authors.initials: BL
authors.lastname: Nørgaard
authors.affiliation: Division of Cardiology, Department of Internal Medicine, Glostrup University Hospital, Glostrup, Denmark.
authors.forename: Jawdat
authors.initials: J
authors.lastname: Abdulla
authors.affiliation: Department of Health Research and Policy, Department of Medicine, Stanford University School of Medicine, Stanford, California.
authors.forename: Jacqueline B
authors.initials: JB
authors.lastname: Shreibati
authors.affiliation: Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
authors.forename: Christian
authors.initials: C
authors.lastname: Torp-Pedersen
authors.affiliation: The Cardiovascular Research Center, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark; The Danish Heart Foundation, Copenhagen, Denmark.
authors.forename: Gunnar H
authors.initials: GH
authors.lastname: Gislason
authors.affiliation: Department of Medicine, Division of Cardiology, California Pacific Medical Center, San Francisco, California.
authors.forename: Richard E
authors.initials: RE
authors.lastname: Shaw
authors.affiliation: Department of Health Research and Policy, Department of Medicine, Stanford University School of Medicine, Stanford, California.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Hlatky
mesh_terms: D000368:Aged; D015331:Cohort Studies; D000072226:Computed Tomography Angiography; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging* / Q000188:drug therapy / Q000401:mortality; D003718:Denmark / Q000453:epidemiology; D004562:Electrocardiography; D005080:Exercise Test; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology
keywords: coronary artery disease; mortality; noninvasive; pharmacotherapy; testing; treatment