Author + information
- Received December 20, 2016
- Revision received January 23, 2017
- Accepted January 23, 2017
- Published online April 3, 2017.
- Mads E. Jørgensen, MBa,b,∗ (, )
- Charlotte Andersson, MD, PhDb,c,
- Bjarne L. Nørgaard, MD, PhDd,
- Jawdat Abdulla, MD, PhDc,
- Jacqueline B. Shreibati, MDa,
- Christian Torp-Pedersen, DMSce,
- Gunnar H. Gislason, MD, PhDb,f,
- Richard E. Shaw, MA, PhDg and
- Mark A. Hlatky, MDa
- aDepartment of Health Research and Policy, Department of Medicine, Stanford University School of Medicine, Stanford, California
- bThe Cardiovascular Research Center, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- cDivision of Cardiology, Department of Internal Medicine, Glostrup University Hospital, Glostrup, Denmark
- dDepartment of Cardiology, Aarhus University Hospital-Skejby, Aarhus, Denmark
- eDepartment of Health Science and Technology, Aalborg University, Aalborg, Denmark
- fThe Danish Heart Foundation, Copenhagen, Denmark
- gDepartment of Medicine, Division of Cardiology, California Pacific Medical Center, San Francisco, California
- ↵∗Address for correspondence:
Dr. Mads E. Jørgensen, Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, The Cardiovascular Research Center, Niels Andersens Vej 65, 2900 Hellerup, Denmark.
Background The choice of either anatomical or functional noninvasive testing to evaluate suspected coronary artery disease might affect subsequent clinical management and outcomes.
Objectives This study analyzed the association of initial noninvasive cardiac testing in outpatients with stable symptoms, with subsequent use of medications, invasive procedures, and clinical outcomes.
Methods We studied patients enrolled in a Danish nationwide register who underwent initial noninvasive cardiac testing with either coronary computed tomography angiography (CTA) or functional testing (exercise electrocardiography or nuclear stress testing) from 2009 to 2015. Further use of noninvasive testing, invasive procedures, medications, and medical costs within 120 days were evaluated. Risks of long-term mortality and myocardial infarction (MI) were analyzed using adjusted Cox proportional hazard models.
Results A total of 86,705 patients underwent either functional testing (n = 53,744, mean age 57.4 years, 49% males) or coronary CTA (n = 32,961, mean age 57.4 years, 45% males), and were followed for a median of 3.6 years. Compared with functional testing, there was significantly higher use of statins (15.9% vs. 9.1%), aspirin (12.7% vs. 8.5%), invasive coronary angiography (14.7% vs. 10.1%), and percutaneous coronary intervention (3.8% vs. 2.1%); all p < 0.001 after coronary CTA. The mean costs of subsequent testing, invasive procedures, and medications were higher after coronary CTA ($995 vs. $718; p < 0.001). Unadjusted rates of mortality (2.1% vs. 4.0%) and MI hospitalization (0.8% vs. 1.5%) were lower after coronary CTA than functional testing (both p < 0.001). After adjustment, coronary CTA was associated with a comparable all-cause mortality (hazard ratio: 0.96; 95% confidence interval: 0.88 to 1.05), and a lower risk of MI (hazard ratio: 0.71; 95% confidence interval: 0.61 to 0.82).
Conclusions In stable patients undergoing initial evaluation for suspected coronary artery disease, coronary CTA was associated with greater use of statins, aspirin, and invasive procedures, and higher costs than functional testing. Coronary CTA was associated with a lower risk of MI, but a similar risk of all-cause mortality.
This work was supported by a grant from the Lundbeck Foundation to the Innovation Center Denmark to fund the Lundbeck Foundation Clinical Research Fellowship for Mr. Jørgensen at the Department of Health Research and Policy, Stanford University. Mr. Jørgensen received further financial support from the Snedkermester Sophus Jacobsen and hustru Astrid Jacobsens Foundation. Dr. Nørgaard has received unrestricted institutional research grants from Siemens, Edwards Lifesciences, and HeartFlow. Dr. Torp-Pedersen has received support from Biotronic for a meta-analysis of ICD implantations; and speaker honoraria and scientific support for anticoagulation studies and support for epidemiological studies and a trial pertaining to anticoagulation from Bayer. Dr. Gislason is supported by an unrestricted clinical research scholarship from the Novo Nordisk Foundation. Dr. Hlatky is supported by unrestricted research grants from HeartFlow Inc. None of the funding sources had any influence on the design of this study, data interpretation, manuscript drafting, or decision to submit for publication. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. This work was presented as a poster at the European Society of Cardiology Conference, 2016, Rome, Italy. Ron Blankstein, MD, served as the Guest Editor for this article.
- Received December 20, 2016.
- Revision received January 23, 2017.
- Accepted January 23, 2017.
- 2017 American College of Cardiology Foundation