Dodd Jonathan D, Bosserdt Maria, Oleksiak Anna, Vattay Borbála, Bech Møller Mathias, Benedek Theodora M, Campbell Fraser, Rodríguez-Palomares José F, Flynn Sebastian, Serna-Higuita Lina M, Sox Harold, Dewey Marc
Department of Radiology, St. Vincent's University Hospital, Elm Park, Dublin 4, D04 T6FA, Ireland.
School of Medicine, University College Dublin, Dublin, Ireland.
Radiol Cardiothorac Imaging. 2025 Aug;7(4):e240526. doi: 10.1148/ryct.240526.
Purpose To compare functional testing and management after cardiac CT-first versus invasive coronary angiography (ICA)-first strategies in participants with stable chest pain and low to intermediate probability of obstructive coronary artery disease (CAD) initially referred for ICA. Materials and Methods This study was a prespecified secondary analysis of the prospective, multicenter, randomized DISCHARGE (Diagnostic Imaging Strategies for Participants with Stable Chest Pain and Intermediate Risk of Coronary Artery Disease) trial (ClinicalTrials.gov no. NCT02400229) conducted between October 2015 and April 2019. The primary outcome was functional testing rates at each of the study sites after first test; secondary outcomes included revascularization, major postprocedure complications, and angina after a 3.5-year follow-up, all stratified by CAD severity. Comparisons were performed using adjusted multiple regression. Results Of 3561 participants (mean age, 60.1 years ± 10.1 [SD]; 2002 [56.2%] female), 3414 were included in the final analysis. CT-first resulted in more functional testing for obstructive CAD without high-risk anatomy as compared with ICA-first (114 of 214 [53.3%] vs 62 of 255 [24.3%]; adjusted odds ratio [OR], 3.55; 95% CI: 2.40, 5.28; < .001). Revascularizations were lower for CT-first in obstructive CAD with high-risk anatomy (146 of 251 [58.2%] vs 161 of 196 [82.1%]; adjusted OR, 0.3; 95% CI: 0.19, 0.47) and without high-risk anatomy (81 of 214 [37.9%] vs 152 of 255 [59.6%]; adjusted OR, 0.41; 95% CI: 0.28, 0.60). ICA-first had more major complications with high-risk anatomy (11 of 196 [5.6%] vs five of 251 [2.0%]) and non-high-risk anatomy (11 of 255 [4.3%] vs two of 214 [0.9%]) than CT-first. Angina rates were similar (38 of 465 [8.2%] vs 32 of 451 [7.1%]; adjusted OR, 1.13; 95% CI: 0.69, 1.86). Conclusion A CT-first strategy increased functional testing, was influenced by CAD severity, and reduced revascularizations and major complications with similar angina rates after a 3.5-year follow-up compared with an ICA-first strategy in participants with stable chest pain. CT Coronary Angiography, Coronary Arteries, Percutaneous, MR Perfusion, Cardiac, Heart, Comparative Studies Clinical trial registration no. NCT02400229 © RSNA, 2025.
目的 比较在最初因稳定型胸痛且阻塞性冠状动脉疾病（CAD）可能性低至中等而被转诊接受有创冠状动脉造影（ICA）的参与者中，先进行心脏CT与先进行ICA两种策略后的功能测试及管理情况。材料与方法 本研究是对2015年10月至2019年4月进行的前瞻性、多中心、随机DISCHARGE（稳定型胸痛和冠状动脉疾病中度风险参与者的诊断成像策略）试验（ClinicalTrials.gov编号：NCT02400229）的预先指定的二次分析。主要结局是首次检查后各研究地点的功能测试率；次要结局包括3.5年随访后的血运重建、主要术后并发症及心绞痛情况，所有这些均按CAD严重程度分层。采用调整后的多元回归进行比较。结果 在3561名参与者（平均年龄60.1岁±10.1[标准差]；2002名[56.2%]为女性）中，3414名被纳入最终分析。与先进行ICA相比，先进行CT对无高危解剖结构的阻塞性CAD进行功能测试更多（214名中的114名[53.3%]对255名中的62名[24.3%]；调整后的优势比[OR]为3.55；95%置信区间：2.40，5.28；P<0.001）。在先进行CT的有高危解剖结构的阻塞性CAD中血运重建率较低（251名中的146名[58.2%]对196名中的161名[82.1%]；调整后的OR为0.3；95%置信区间：0.19，0.47），在无高危解剖结构的情况下也是如此（214名中的81名[37.9%]对255名中的152名[59.6%]；调整后的OR为0.41；95%置信区间：0.28，0.60）。与先进行CT相比，先进行ICA在有高危解剖结构（196名中的11名[5.6%]对251名中的5名[2.0%]）和无高危解剖结构（255名中的11名[4.3%]对214名中的2名[0.9%]）时主要并发症更多。心绞痛发生率相似（465名中的38名[8.2%]对451名中的32名[7.1%]；调整后的OR为1.13；95%置信区间：0.69，1.86）。结论 与先进行ICA策略相比，先进行CT策略增加了功能测试，受CAD严重程度影响，减少了血运重建和主要并发症，在对稳定型胸痛参与者进行3.5年随访后心绞痛发生率相似。CT冠状动脉造影、冠状动脉、经皮、MR灌注、心脏、心脏、比较研究 临床试验注册号：NCT02400229 ©RSNA，2025
