Michael T Lu1, Pamela S Douglas2, James E Udelson3, Elizabeth Adami4, Brian B Ghoshhajra5, Michael H Picard6, Rhonda Roberts7, Kerry L Lee8, Andrew J Einstein9, Daniel B Mark10, Eric J Velazquez11, William Carter12, Michael Ridner13, Hussein R Al-Khalidi14, Udo Hoffmann15. 1. Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA. Electronic address: mlu@mgh.harvard.edu. 2. Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA. Electronic address: pamela.douglas@dm.duke.edu. 3. Tufts Medical School, Boston, MA, USA. Electronic address: judelson@tuftsmedicalcenter.org. 4. Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA. Electronic address: eadami@partners.org. 5. Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA. Electronic address: bghoshhajra@mgh.harvard.edu. 6. Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA. Electronic address: mhpicard@mgh.harvard.edu. 7. Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA. Electronic address: rhonda.s.roberts@duke.edu. 8. Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA. Electronic address: kerry.lee@duke.edu. 9. Columbia University Medical Center and New York-Presbyterian Hospital, New York, NY, USA. Electronic address: ae2214@columbia.edu. 10. Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA. Electronic address: daniel.mark@dm.duke.edu. 11. Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA. Electronic address: eric.velazquez@duke.edu. 12. Charleston Area Medical Center, Charleston, WV, USA. Electronic address: william.carter@camc.org. 13. University of Alabama School of Medicine, Huntsville, AL, USA. Electronic address: mridner@theheartcenter.md. 14. Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA. Electronic address: hussein.al-khalidi@duke.edu. 15. Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA. Electronic address: uhoffmann@partners.org.
Abstract
BACKGROUND:Coronary computed tomography angiography (CTA) and functional testing strategies for stable chest pain yield similar outcomes; one aspect that may guide test choice is safety. METHODS: We compared test safety (test complications, incidental findings, and effective radiation dose) between CTA and functional testing as-tested in PROMISE (PROspective Multicenter Imaging Study for Evaluation of Chest Pain). In the subgroup whose physicians intended nuclear stress over other functional tests if randomized to the functional arm, we compared radiation dose of CTA versus nuclear stress and identified characteristics associated with dose. RESULTS: Of 9470 patients, none had major and <1% had minor complications (CTA: 0.8% [37/4633] vs. functional: 0.6% [27/4837]). CTA identified more incidental findings (11.6% [539/4633] vs. 0.7% [34/4837], p < 0.001), most commonly pulmonary nodules (9.4%, 437/4633). CTA had similar 90-day cumulative radiation dose to functional testing. However, in the subgroup whose physicians intended nuclear stress (CTA 3147; nuclear 3203), CTA had lower median index test (8.8 vs. 12.6 mSv, p < 0.001) and 90-day cumulative (11.6 vs. 13.1 mSv, p < 0.001) dose, independent of patient characteristics. The lowest nuclear doses employed 1-day Tc-99m protocols (12.2 mSv). The lowest CTA doses were at sites performing ≥500 CTAs/year (6.9 mSv) and with advanced (latest available) CT scanners (5.5 mSv). CONCLUSION: Complications were negligibly rare for both CTA and functional testing. CTA detects more incidental findings. Compared to nuclear stress testing, CTA's lower radiation dose, independent of patient characteristics, makes it an attractive test choice. Radiation dose varies with imaging protocol, indicating opportunities to further reduce dose. (ClinicalTrials.gov number, NCT01174550).
RCT Entities:
BACKGROUND: Coronary computed tomography angiography (CTA) and functional testing strategies for stable chest pain yield similar outcomes; one aspect that may guide test choice is safety. METHODS: We compared test safety (test complications, incidental findings, and effective radiation dose) between CTA and functional testing as-tested in PROMISE (PROspective Multicenter Imaging Study for Evaluation of Chest Pain). In the subgroup whose physicians intended nuclear stress over other functional tests if randomized to the functional arm, we compared radiation dose of CTA versus nuclear stress and identified characteristics associated with dose. RESULTS: Of 9470 patients, none had major and <1% had minor complications (CTA: 0.8% [37/4633] vs. functional: 0.6% [27/4837]). CTA identified more incidental findings (11.6% [539/4633] vs. 0.7% [34/4837], p < 0.001), most commonly pulmonary nodules (9.4%, 437/4633). CTA had similar 90-day cumulative radiation dose to functional testing. However, in the subgroup whose physicians intended nuclear stress (CTA 3147; nuclear 3203), CTA had lower median index test (8.8 vs. 12.6 mSv, p < 0.001) and 90-day cumulative (11.6 vs. 13.1 mSv, p < 0.001) dose, independent of patient characteristics. The lowest nuclear doses employed 1-day Tc-99m protocols (12.2 mSv). The lowest CTA doses were at sites performing ≥500 CTAs/year (6.9 mSv) and with advanced (latest available) CT scanners (5.5 mSv). CONCLUSION: Complications were negligibly rare for both CTA and functional testing. CTA detects more incidental findings. Compared to nuclear stress testing, CTA's lower radiation dose, independent of patient characteristics, makes it an attractive test choice. Radiation dose varies with imaging protocol, indicating opportunities to further reduce dose. (ClinicalTrials.gov number, NCT01174550).
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