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J Am Coll Cardiol. 2019 Mar 5;73(8):893-902. doi: 10.1016/j.jacc.2018.11.056.

Stress Testing Versus CT Angiography in Patients With Diabetes and Suspected Coronary Artery Disease.

Author information

1
Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiology, Stanford University, Palo Alto, California.
2
Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
3
Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
4
Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina. Electronic address: pamela.douglas@duke.edu.

Abstract

BACKGROUND:

The optimal noninvasive test (NIT) for patients with diabetes and stable symptoms of coronary artery disease (CAD) is unknown.

OBJECTIVES:

The purpose of this study was to assess whether a diagnostic strategy based on coronary computed tomographic angiography (CTA) is superior to functional stress testing in reducing adverse cardiovascular (CV) outcomes (CV death or myocardial infarction [MI]) among symptomatic patients with diabetes.

METHODS:

PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) was a randomized trial evaluating an initial strategy of CTA versus functional testing in stable outpatients with symptoms suggestive of CAD. The study compared CV outcomes in patients with diabetes (n = 1,908 [21%]) and without diabetes (n = 7,058 [79%]) based on their randomization to CTA or functional testing.

RESULTS:

Patients with diabetes (vs. without) were similar in age (median 61 years vs. 60 years) and sex (female 54% vs. 52%) but had a greater burden of CV comorbidities. Patients with diabetes who underwent CTA had a lower risk of CV death/MI compared with functional stress testing (CTA: 1.1% [10 of 936] vs. stress testing: 2.6% [25 of 972]; adjusted hazard ratio: 0.38; 95% confidence interval: 0.18 to 0.79; p = 0.01). There was no significant difference in nondiabetic patients (CTA: 1.4% [50 of 3,564] vs. stress testing: 1.3% [45 of 3,494]; adjusted hazard ratio: 1.03; 95% confidence interval: 0.69 to 1.54; p = 0.887; interaction term for diabetes p value = 0.02).

CONCLUSIONS:

In diabetic patients presenting with stable chest pain, a CTA strategy resulted in fewer adverse CV outcomes than a functional testing strategy. CTA may be considered as the initial diagnostic strategy in this subgroup. (PROspective Multicenter Imaging Study for Evaluation of Chest Pain [PROMISE]; NCT01174550).

KEYWORDS:

cardiovascular outcomes; chest pain; coronary computed tomographic angiography; diabetes; stress testing

PMID:
30819356
DOI:
10.1016/j.jacc.2018.11.056

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