Whether Angio or CT Come First in Evaluating Chest Pain, QoL After Is Similar

Long-term quality of life and symptoms are similar in patients with chest pain regardless of whether they’re first evaluated by computed tomography (CT) or by invasive coronary angiography (ICA), according to new data from the DISCHARGE trial.

While women got a boost in quality of life with either strategy, they had worse health status compared with men at both baseline and median 3.5-year follow-up.

“This result is important for clinical practice because it informs the conversation between clinician and patient about which test to perform,” Nina Rieckmann, PhD (Charité–Universitätsmedizin Berlin, Germany), and colleagues write in their paper published online last week in JAMA Cardiology. “The clinician can tell the patient that the outcome they hope for is equally likely irrespective of which test they choose to undergo.”

DISCHARGE was considered a win for CT angiography in the evaluation of patients with stable chest pain when it was first presented in 2022. In the trial, there was no significant difference in the risk of MACE with the noninvasive test compared with cardiac catheterization over 3.5 years of follow-up, but ICA was associated with a higher risk of complications. Additional data from last year confirmed the same benefits in older patients.

Maros Ferencik, MD, PhD (Oregon Health & Science University, Portland), who commented on the new analysis for TCTMD, said the latest results further cement the important role of CT in this care pathway, adding that current US guidelines already recommend using a noninvasive test first. “This study was started before that guideline, and this is of course a European study where there are still a lot of places where [patients] go directly to the cath lab,” he said.

Still, Ferencik added, “it is in a way a win for CT from the perspective that you can do the CT and guide the right patients to the cath lab and still have the same quality of life of outcomes.”

Quality of Life Outcomes

The quality-of-life analysis included 3,561 European patients from DISCHARGE (mean age 60.1 years; 56.2% female) who completed at least one health status assessment over 3.5 years of follow-up. Questionnaires used included:

• Euro QOL 5-dimensions descriptive system (EQ-5D-3L)
• Euro QOL 5-dimensions descriptive system visual analog scale (EQ-5D-3L-VAS)
• Euro QOL 5-dimensions descriptive system summary index (EQ-5D-3L-SI)
• 12-item Short Form Health Survey (SF-12)
• 12-item Short Form Health Survey physical component score (SF-12-PCS)
• 12-item Short Form Health Survey mental component summary (SF-12-MCS)
• Hospital Anxiety and Depression Scale–anxiety subscale (HADS-A)
• Hospital Anxiety and Depression Scale–anxiety subscale (HADS-D)

There were significant improvements in quality of life across all outcomes regardless of CT or ICA assignment, with the exception of HADS-D, which only improved in the CT cohort.

Notably, quality of life assessed by EQ-5D-3L-VAS was lower in women compared with men at both baseline and follow-up, but women reported greater gains in EQ-5D-3L-VAS, SF-12-PCS, and HADS-A compared with men (P < 0.05 for all).

There were similar angina rates between the groups at 3.5 years. At 1 year, though, women reported more angina than men in the ICA group (10.2% vs 6.2%; P = 0.007) and were still more likely to report angina at 3.5 years (OR 1.52; 95% CI 1.21-1.9).

Patients who were younger and those with depressive symptoms perceived greater health gains (EQ-VAS) compared with older patients and those who were not depressed at baseline. Patients who underwent revascularization reported greater improvements in the SF-12 PCS among all subgroups as well as compared with patients who did not have revascularization. CAD status did not affect the magnitude of change in quality of life.

‘Reassuring’ Data, More Questions

Ferencik praised the authors for their comprehensiveness in including so many different questionnaires as well as thorough subgroup analyses. The fact that the main findings hold true in all subgroups is “reassuring,” he added.

The sex differences observed in the study open a window to big-picture questions that physicians should be exploring, Ferencik said. “It makes us pause and think about what are the socioeconomic reasons for it? Are there things within the healthcare system that we can do to improve this disparity?”

Deciding whether to offer an intervention to patients is “only one piece of the puzzle,” he said. “Going beyond that, understanding what needs to be done is perhaps the next step.”