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J Am Heart Assoc. 2017 Jul 19;6(7). pii: e005462. doi: 10.1161/JAHA.116.005462.

Comparison of Anatomic and Clinical Outcomes in Patients Undergoing Alternative Initial Noninvasive Testing Strategies for the Diagnosis of Stable Coronary Artery Disease.

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Institute for Clinical Evaluative Sciences (ICES), University of Toronto, Ontario, Canada.
Schulich Heart Program and the Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada.
Department of Medical Biophysics, University of Toronto, Ontario, Canada.
Institute for Clinical Evaluative Sciences (ICES), University of Toronto, Ontario, Canada



The optimal initial noninvasive diagnostic testing strategy for stable coronary artery disease (CAD) is unknown. Although American guidelines recommend an exercise stress test as the first-line test, European guidelines suggest that stress imaging (myocardial perfusion imaging or stress echocardiography) or coronary computed tomography angiography may be preferable. Understanding the relationship between the initial strategy and downstream yield of obstructive CAD and major adverse cardiac events may provide insight as to the optimal strategy.


We conducted a population-based retrospective cohort study of adults in Ontario, Canada, using health administrative and clinical data. The relationship between the initial testing strategy and obstructive CAD on invasive angiography was examined. Patients were then followed from their angiogram onward to determine whether they developed a composite end point of major adverse cardiac events. After adjusting for covariates, patients with initial myocardial perfusion imaging (odds ratio: 0.92; 95% confidence interval, 0.85, 1.00), coronary computed tomography angiography (odds ratio: 1.51; 95% confidence interval, 0.91, 2.49), or stress echo (odds ratio: 0.95; 95% confidence interval, 0.84, 1.08) did not a have significantly different yield of obstructive CAD compared with those with an initial exercise stress test. Furthermore, there was no significant difference in downstream major adverse cardiac events after invasive angiography among the 4 initial testing strategies after adjusting for clinically relevant covariates.


Our study found no evidence to suggest significant differences in either yield of obstructive CAD or downstream major adverse cardiac events in patients undergoing an initial noninvasive testing strategy with stress or anatomical imaging compared with those undergoing an initial exercise stress test.


coronary computed tomography; exercise stress testing; myocardial perfusion imaging; noninvasive diagnostic testing; stable coronary artery disease

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