BACKGROUND In the diagnosis of obstructive coronary artery disease (CAD), computed
tomography (CT) is an accurate, noninvasive alternative to invasive coronary angiography
(ICA). However, the comparative effectiveness of CT and ICA in the management of CAD
to reduce the frequency of major adverse cardiovascular events is uncertain. METHODS
We conducted a pragmatic, randomized trial comparing CT with ICA as initial diagnostic
imaging strategies for guiding the treatment of patients with stable chest pain who
had an intermediate pretest probability of obstructive CAD and were referred for ICA
at one of 26 European centers. The primary outcome was major adverse cardiovascular
events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke)
over 3.5 years. Key secondary outcomes were procedure-related complications and angina
pectoris. RESULTS Among 3561 patients (56.2% of whom were women), follow-up was complete
for 3523 (98.9%). Major adverse cardiovascular events occurred in 38 of 1808 patients
(2.1%) in the CT group and in 52 of 1753 (3.0%) in the ICA group (hazard ratio, 0.70;
95% confidence interval [CI), 0.46 to 1.07; P=0.10). Major procedure-related complications
occurred in 9 patients (0.5%) in the CT group and in 33 (1.9%) in the ICA group (hazard
ratio, 0.26; 95% CI, 0.13 to 0.55). Angina during the final 4 weeks of follow-up was
reported in 8.8% of the patients in the CT group and in 7.5% of those in the ICA group
(odds ratio, 1.17; 95% CI, 0.92 to 1.48). CONCLUSIONS Among patients referred for
ICA because of stable chest pain and intermediate pretest probability of CAD, the
risk of major adverse cardiovascular events was similar in the CT group and the ICA
group. The frequency of major procedure-related complications was lower with an initial
CT strategy.
