DM and symptomatic CAD: CTA looks better as an initial tool

  • J Am Coll Cardiol

  • curated by Jenny Blair, MD
  • Clinical Essentials
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Takeaway

  • For people with diabetes mellitus (DM) and symptomatic coronary artery disease (CAD), coronary computed tomographic angiography (CTA) is linked to a lower rate of subsequent adverse cardiovascular outcomes vs functional stress testing (FST). 
  • Editorial:
    • Likeliest explanation is that patients "undergoing coronary CTA receive aspirin and statin therapy more often than those undergoing stress testing."
    • Urges first-line CTA for new-onset, stable cardiac chest pain.

Why this matters

  • For screening asymptomatic patients with diabetes, no noninvasive CAD test has been linked to better outcomes.

Key results

  • 42-month follow-up.
  • Primary outcome, participants with vs without diabetes: adjusted HR (aHR), 1.40 (95% CI, 1.07-1.83; P=.015).
  • No difference in primary outcome with CTA vs FST among participants either with or without diabetes.
  • Cardiovascular death/myocardial infarction (MI) with CTA vs FST among:
    • Participants with diabetes: aHR, 0.38 (95% CI, 0.18-0.79; P=.01).
    • Nondiabetic participants: no difference.

Study design

  • Planned subgroup analysis of PROMISE (n=8966).
  • Outpatients with symptoms of stable CAD randomly assigned to initial evaluation with CTA vs FST.
  • Outcomes compared between participants with vs without diabetes.
  • Outcome: composite of death, MI, unstable angina hospitalization.
  • Funding: NIH.

Limitations

  • Retrospective.
  • Low number of cardiovascular events.
  • Noncardiovascular deaths among participants with diabetes may have obscured CTA benefit for primary outcome.

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