CT-FIRST: Cardiac Computed Tomography Versus Stress Imaging For Initial Risk STratification

The current evaluation for chest pain in low and intermediate risk patients typically starts
with a functional assessment for coronary ischemia. Exercise treadmill testing is often
selected as the initial diagnostic modality for coronary artery function. However, exercise
treadmill testing is limited by its modest sensitivity and specificity, often resulting in
further cardiac resource utilization for patient risk stratification and reassurance.
Additionally, many patients with chest pain are not candidates for regular stress testing
due to an abnormal baseline electrocardiogram or inability to exercise. Therefore, exercise
or pharmacologic stress imaging is considered the standard of care for the evaluation of
coronary artery function in a large percentage of patients with chest pain. However, each
of the currently available stress imaging tests has well-documented limitations, resulting
in a sizeable number of false negative and false positive studies. With the advent of
coronary Multislice Computed Tomography (MSCT) angiography, coronary artery anatomy can now
be accurately evaluated noninvasively. Despite its impressive performance characteristics,
the role of coronary MSCT angiography in the evaluation of angina remains undefined.
Furthermore, studies comparing MSCT to stress imaging are lacking. CT-FIRST compares the
impact on downstream resource utilization and patient outcomes of an initial diagnostic
strategy employing the addition of coronary MSCT angiography to stress imaging (exercise and
pharmacologic stress echo and nuclear perfusion testing) with a standard-of-care diagnostic
strategy of stress imaging for the evaluation of low-intermediate risk patients with
possible angina. The study is a single center, prospective, non-blinded, randomized
clinical trial.