Results:

Of 400 patients randomized at Montefiore Medical Center, 201 were assigned to coronary CTA and 199 to stress echocardiography. Patients had resolution of chest pain and negative serum troponin at least 8 hours after onset of symptoms. Patients were excluded for evidence of myocardial infarction or ischemia on electrocardiogram, hemodynamic instability, crescendo or persistent chest pain, contraindications to coronary CTA or stress echocardiography, or prior coronary CTA, stress echocardiography, or cardiac catheterization within the previous 6 months. Patients presented between August 2011 and January 2016. Mean patient age was 55.0 years + 9.7 years, with 42.5% female and 87.3% ethnic minorities. A minimum of 1 year of follow-up was completed in 97%. Outcomes were assessed by intention to treat. Coronary CTA was performed on 189 of 201 patients, and stress echocardiography was performed on 188 of 199.

• Hospitalization rate for the coronary CTA group was 19% versus 11% for the stress echocardiography group (difference 8%; 95% confidence interval 1-15%; p = 0.026).
• Median length of stay in discharged patients (time from randomization to discharge) in the coronary CTA group was 5.4 hours versus 4.7 hours in the stress echocardiography group (p < 0.001).
• Median length of stay in admitted patients (time from admission order to discharge) in the coronary CTA group was 58 hours versus 34 hours in the stress echocardiography group (p = 0.002).
• Safety outcomes showed no statistically significant differences in rates of major adverse cardiovascular events, all-cause death, nonfatal myocardial infarction, nonfatal stroke, nonfatal cardiac arrest, cardiac catheterization, revascularization from coronary artery bypass graft surgery or percutaneous coronary intervention, or serious complications from noninvasive imaging or revascularization over a median follow-up period of 733 days.
• New or increased pharmacotherapy for lipid-lowering medication in the coronary CTA arm was 14% versus 6% in the stress echocardiography arm (p = 0.01). In the coronary CTA group, beta-blocker medications were newly prescribed for 9% versus 4% in the stress echocardiography group (p = 0.04).
• Resource utilization showed no statistically significant differences in subsequent hospitalizations, emergency department visits, primary care visits, or cardiology outpatient visits over the complete follow-up period. Coronary CTA demonstrated alternate pathology in 10 patients: aortic intramural hematoma, ascending aortic aneurysm, stenotic bicuspid aortic valve, pulmonary emboli (3 patients), malignant pleural effusion, pneumonia, cholangiocarcinoma, and liver metastases. There were more admissions in the coronary CTA group for further assessment of diagnosed coronary artery disease, non-chest pain complaints, and pulmonary embolism.
• Radiation exposure was decreased in the stress echocardiography group through all evaluation periods.
• Subjective experience on multiple measures was more favorably rated by patients in the stress echocardiography group.