Comparative Analysis of Cardiac CT and Invasive Coronary Angiography for Suspected Stable Coronary Artery Disease and Subsequent Functional Testing and Revascularization: A Prespecified Secondary DISCHARGE Randomized Trial Analysis.

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; P_interaction < .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. Keywords: CT Coronary Angiography, Coronary Arteries, Percutaneous, MR Perfusion, Cardiac, Heart, Comparative Studies Clinical trial registration no. NCT02400229 Supplemental material is available for this article. © RSNA, 2025.