Jeffrey M. Levsky, MD, PhD; Daniel M. Spevack, MD, MS; Mark I. Travin, MD; Mark A. Menegus, MD; Paul W. Huang, MD; Elana T. Clark, MD; Choo-won Kim, MD; Esther Hirschhorn, BS; Katherine D. Freeman, DrPH; Jonathan N. Tobin, PhD; Linda B. Haramati, MD, MS
Acknowledgment: The authors thank study coordinators Rizwan Aslam, Prameela Banoth, Shimon Farkas, Adina Haramati, Raphael Hulkower, David Kawior, Kristen Launier, Rikah Lerer, Shey Mukundan, Dieudonne Nonga, Paul O'Connor, Danny Nhan, Shayne Sebold, Samantha Selesny, Daniel Sova, Christian Stanton, and Shayna Vega. They thank Hannah Simons for help with statistical analyses and Nina Ackerman for help with analyzing socioeconomic status. They also acknowledge the contribution of the study's data and safety monitoring board members: Drs. Michael Farkouh, Gregory Pearson, Yungtai Lo, Michelle Johnson, and James Godbold.
Grant Support: By the American Heart Association Clinical Research Program (grant 0885024D) and the National Center for Advancing Translational Sciences (Clinical and Translational Science Award grants 1 UL1 TR001073-01), a component of the National Institutes of Health.
Disclosures: Dr. Travin reports a grant and other funds from GE Healthcare during the conduct of this study. Dr. Tobin reports receiving grants from National Institutes of Health, Agency for Healthcare Research and Quality, Patient-Centered Outcomes Research Institute, and Centers for Disease Control and Prevention during the conduct of the study. Dr. Levsky reports grants from American Heart Association during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOf InterestForms.do?msNum=M14-2948.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Reproducible Research Statement:Study protocol, data set, and statistical code: Available from Dr. Levsky (e-mail, firstname.lastname@example.org). Statistical code: Not applicable.
Requests for Single Reprints: Jeffrey M. Levsky, MD, PhD, Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467-2490; e-mail, email@example.com.
Current Author Addresses: Drs. Levsky and Haramati: Division of Cardiothoracic Imaging, Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467-2490.
Drs. Spevack and Menegus: Division of Cardiology, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467-2490.
Dr. Travin: Division of Nuclear Medicine, Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467-2490.
Dr. Huang: Division of Hospital Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467-2490.
Dr. Clark: Cohen Children's Medical Center, 269-01 76th Avenue, New Hyde Park, NY 11040.
Dr. Kim: Department of Radiology, Stony Brook School of Medicine, 100 Nicolls Road, HSC L4 Room 120, Stony Brook, NY 11794-8460.
Ms. Hirschhorn: 1925 Eastchester Road, Apartment 6A, Bronx, NY 10461.
Dr. Freeman: Extrapolate Statistics, 1145 Harbor Drive, Suite 1A, Delray Beach, FL 33483.
Dr. Tobin: Clinical Directors Network, 5 West 37th Street, 10th Floor, New York, NY 10018.
Author Contributions: Conception and design: J.M. Levsky, D.M. Spevack, M.I. Travin, K.D. Freeman, J.N. Tobin, L.B. Haramati.
Analysis and interpretation of the data: J.M. Levsky, D.M. Spevack, M.I. Travin, M.A. Menegus, E. Hirschhorn, K.D. Freeman, J.N. Tobin, L.B. Haramati.
Drafting of the article: J.M. Levsky, M.A. Menegus, J.N. Tobin, L.B. Haramati.
Critical revision for important intellectual content: J.M. Levsky, D.M. Spevack, M.I. Travin, M.A. Menegus, E.T. Clark, C. Kim, E. Hirschhorn, K.D. Freeman, J.N. Tobin, L.B. Haramati.
Final approval of the article: J.M. Levsky, D.M. Spevack, M.I. Travin, M.A. Menegus, E.T. Clark, C. Kim, E. Hirschhorn, J.N. Tobin, L.B. Haramati.
Provision of study materials or patients: M.I. Travin, L.B. Haramati.
Statistical expertise: J.M. Levsky, K.D. Freeman, J.N. Tobin.
Obtaining of funding: J.M. Levsky, J.N. Tobin.
Administrative, technical, or logistic support: D.M. Spevack, M.A. Menegus, E.T. Clark, J.N. Tobin. L.B. Haramati.
Collection and assembly of data: J.M. Levsky, E.T. Clark, C. Kim, E. Hirschhorn, J.N. Tobin, L.B. Haramati.
Levsky JM, Spevack DM, Travin MI, Menegus MA, Huang PW, Clark ET, et al. Coronary Computed Tomography Angiography Versus Radionuclide Myocardial Perfusion Imaging in Patients With Chest Pain Admitted to Telemetry: A Randomized Trial. Ann Intern Med. 2015;163:174-183. doi: 10.7326/M14-2948
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Published: Ann Intern Med. 2015;163(3):174-183.
The role of coronary computed tomography angiography (CCTA) in the management of symptomatic patients suspected of having coronary artery disease is expanding. However, prospective intermediate-term outcomes are lacking.
To compare CCTA with conventional noninvasive testing.
Randomized, controlled comparative effectiveness trial. (ClinicalTrials.gov: NCT00705458)
Telemetry-monitored wards of an inner-city medical center.
400 patients with acute chest pain (mean age, 57 years); 63% women; 54% Hispanic and 37% African-American; and low socioeconomic status.
CCTA or radionuclide stress myocardial perfusion imaging (MPI).
The primary outcome was cardiac catheterization not leading to revascularization within 1 year. Secondary outcomes included length of stay, resource utilization, and patient experience. Safety outcomes included death, major cardiovascular events, and radiation exposure.
Thirty (15%) patients who had CCTA and 32 (16%) who had MPI underwent cardiac catheterization within 1 year. Fifteen (7.5%) and 20 (10%) of these patients, respectively, did not undergo revascularization (difference, −2.5 percentage points [95% CI, −8.6 to 3.5 percentage points]; hazard ratio, 0.77 [CI, 0.40 to 1.49]; P = 0.44). Median length of stay was 28.9 hours for the CCTA group and 30.4 hours for the MPI group (P = 0.057). Median follow-up was 40.4 months. For the CCTA and MPI groups, the incidence of death (0.5% versus 3%; P = 0.12), nonfatal cardiovascular events (4.5% versus 4.5%), rehospitalization (43% versus 49%), emergency department visit (63% versus 58%), and outpatient cardiology visit (23% versus 21%) did not differ. Long-term, all-cause radiation exposure was lower for the CCTA group (24 versus 29 mSv; P < 0.001). More patients in the CCTA group graded their experience favorably (P = 0.001) and would undergo the examination again (P = 0.003).
This was a single-site study, and the primary outcome depended on clinical management decisions.
The CCTA and MPI groups did not significantly differ in outcomes or resource utilization over 40 months. Compared with MPI, CCTA was associated with less radiation exposure and with a more positive patient experience.
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