Comparison of Anatomic and Clinical Outcomes in Patients Undergoing Alternative Initial Noninvasive Testing Strategies for the Diagnosis of Stable Coronary Artery Disease

• Published in: Journal of the American Heart Association Vol. 6; no. 7
• Main Authors: Roifman, Idan, Wijeysundera, Harindra C., Austin, Peter C., Rezai, Mohammad R., Wright, Graham A., Tu, Jack V.
• Format: Journal Article
• Language: English
• Published: England John Wiley and Sons Inc 01-07-2017; Wiley
• Subjects: Aged; Chi-Square Distribution; Computed Tomography Angiography; Coronary Angiography - methods; Coronary Artery Disease - diagnostic imaging; Coronary Artery Disease - mortality; Coronary Artery Disease - physiopathology; coronary computed tomography; Coronary Vessels - diagnostic imaging; Coronary Vessels - physiopathology; Disease Progression; Echocardiography, Stress - methods; exercise stress testing; Exercise Test; Female; Humans; Kaplan-Meier Estimate; Logistic Models; Male; Middle Aged; Multivariate Analysis; myocardial perfusion imaging; Myocardial Perfusion Imaging - methods; noninvasive diagnostic testing; Odds Ratio; Ontario; Original Research; Predictive Value of Tests; Prognosis; Proportional Hazards Models; Reproducibility of Results; Retrospective Studies; stable coronary artery disease; Time Factors; exercise stress testing; myocardial perfusion imaging; noninvasive diagnostic testing; coronary computed tomography; stable coronary artery disease
• ISSN: 2047-9980; 2047-9980
• DOI: 10.1161/JAHA.116.005462

Background
The optimal initial noninvasive diagnostic testing strategy for stable coronary artery disease (CAD) is unknown. Although American guidelines recommend an exercise stress test as the first‐line test, European guidelines suggest that stress imaging (myocardial perfusion imaging or stress echocardiography) or coronary computed tomography angiography may be preferable. Understanding the relationship between the initial strategy and downstream yield of obstructive CAD and major adverse cardiac events may provide insight as to the optimal strategy.
Methods and Results
We conducted a population‐based retrospective cohort study of adults in Ontario, Canada, using health administrative and clinical data. The relationship between the initial testing strategy and obstructive CAD on invasive angiography was examined. Patients were then followed from their angiogram onward to determine whether they developed a composite end point of major adverse cardiac events. After adjusting for covariates, patients with initial myocardial perfusion imaging (odds ratio: 0.92; 95% confidence interval, 0.85, 1.00), coronary computed tomography angiography (odds ratio: 1.51; 95% confidence interval, 0.91, 2.49), or stress echo (odds ratio: 0.95; 95% confidence interval, 0.84, 1.08) did not a have significantly different yield of obstructive CAD compared with those with an initial exercise stress test. Furthermore, there was no significant difference in downstream major adverse cardiac events after invasive angiography among the 4 initial testing strategies after adjusting for clinically relevant covariates.
Conclusions
Our study found no evidence to suggest significant differences in either yield of obstructive CAD or downstream major adverse cardiac events in patients undergoing an initial noninvasive testing strategy with stress or anatomical imaging compared with those undergoing an initial exercise stress test.