Long-term risks are similar for CT and invasive coronary angiography as initial diagnostic strategy for stable chest pain

Reference

DISCHARGE Trial Group, Maurovich-Horvat P, Bosserdt M, et al. CT or invasive coronary angiography in stable chest pain. N Engl J Med 2022;386(17):1591-1602.

Synopsis

In this study from Europe, the investigators enrolled patients 30 years and older who were referred for invasive coronary angiography (ICA) for stable chest pain and had an intermediate pretest probability (10% - 60%) of obstructive coronary artery disease (CAD). Using concealed allocation, study patients were randomized to undergo either computed tomography angiography (CTA; n = 1833) or ICA (n = 1834) as an initial diagnostic strategy to identify obstructive CAD. Patients found to have obstructive CAD with this initial testing were treated according to guidelines; the rest were referred back to their physicians for further management. The 2 study groups were similar at baseline: median age was 61 years, 56% were female, and one-third had functional stress testing performed prior to enrollment in the trial. Overall, 25% of patients in each group were identified as having obstructive CAD. The primary outcome was a composite of major adverse cardiovascular events, including cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke. After a median follow-up of 3.5 years, the primary outcome was similar in the 2 groups (2.1% in CTA group vs 3.0% in ICA group). Additionally, only 22% of patients in the CTA group had ICA performed during the initial management period, as compared with 97% in the ICA group, resulting in fewer major procedure–related complications with CTA as an initial strategy (0.5% in the CTA group vs 1.9% in the ICA group; hazard ratio 0.26; 95% CI 0.13 - 0.55). During the follow-up period, the CTA group had more functional testing (18.6% vs 12.9%) but required fewer revascularization procedures (14.2% vs 18.0%). There was no significant difference in the incidence of angina (< 10% in both groups) during the last 4 weeks of follow-up.