Should CT Angiography or Invasive Coronary Angiography Be the Initial Diagnostic Test for Stable Angina?

Kirsten E. Fleischmann, MD, MPH, FACC, reviewing 

No significant differences in cardiovascular-related death, myocardial infarction, or stroke were noted between the two strategies during 3.5 years of follow-up.

Either computed tomography angiography (CTA) or invasive coronary angiography (ICA) can be used to diagnose obstructive epicardial coronary artery disease (CAD) in patients with stable angina, but which test strategy is associated with better outcomes? In this pragmatic randomized European trial, investigators compared ICA and CTA as the initial anatomic diagnostic imaging strategy in 3651 patients with stable angina and intermediate pretest probability of CAD who were referred for ICA.

Approximately one third of the cohort underwent functional testing prior to the assigned intervention, and just over one quarter of each group had obstructive CAD (defined as a lesion of 50% or greater). During a median follow-up of 3.5 years, the primary endpoint of cardiovascular-related death or nonfatal myocardial infarction or stroke occurred in 2.1% of the CTA group and in 3.0% of the ICA group — a nonsignificant difference. However, major procedure-related complications were significantly less common in the CTA group (0.5% vs. 1.9%), likely due in part to the fact that only 22% of the CTA patients underwent subsequent ICA during their initial management. Angina symptoms in the final 4 weeks of follow-up were similar in both groups (8.8% in the CT group and 7.5% in the ICA group).


In this trial, an initial strategy of CTA for anatomic imaging was associated with similar outcomes but fewer procedural complications and invasive angiograms. I am increasingly considering CTA as an initial test for workup of patients with stable chest pain and intermediate risk, and these data suggest it could play a “gatekeeper” role as well. However, the authors note that unanswered questions remain, including the comparative cost-effectiveness of the two strategies.


Maurovich-Horvat P et al. CT or invasive coronary angiography in stable chest pain. N Engl J Med 2022 Mar 4; [e-pub]. ( opens in new tab)

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