Safety of coronary CT angiography and functional testing for stable chest pain in the PROMISE trial: A randomized comparison of test complications, incidental findings, and radiation dose

J Cardiovasc Comput Tomogr. 2017 Sep-Oct;11(5):373-382. doi: 10.1016/j.jcct.2017.08.005. Epub 2017 Aug 15.

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).

Keywords: Chest pain; Coronary artery disease; Coronary computed tomography angiography; Functional testing.

Publication types

  • Comparative Study
  • Multicenter Study
  • Randomized Controlled Trial

MeSH terms

  • Aged
  • Angina Pectoris / diagnostic imaging*
  • Angina Pectoris / etiology
  • Computed Tomography Angiography* / adverse effects
  • Coronary Angiography / adverse effects
  • Coronary Angiography / methods*
  • Coronary Artery Disease / complications
  • Coronary Artery Disease / diagnostic imaging*
  • Coronary Stenosis / complications
  • Coronary Stenosis / diagnostic imaging*
  • Echocardiography, Stress* / adverse effects
  • Female
  • Humans
  • Incidental Findings*
  • Male
  • Middle Aged
  • Multidetector Computed Tomography* / adverse effects
  • North America
  • Predictive Value of Tests
  • Prospective Studies
  • Radiation Dosage*
  • Radiation Exposure
  • Radionuclide Imaging* / adverse effects
  • Risk Assessment
  • Risk Factors

Associated data

  • ClinicalTrials.gov/NCT01174550