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Economic Outcomes With Anatomical Versus Functional Diagnostic Testing for Coronary Artery Disease

IN RESPONSE: Dr. Martin makes several interesting points. PROMISE was a pragmatic randomized trial designed to assess the outcomes of 2 diagnostic strategies in symptomatic patients: initial use of CTA or of functional testing (a composite of exercise ECG testing, stress nuclear testing, or stress echocardiography, with the choice of test left up to the managing physician) (1, 2). It was not designed or powered to compare each functional testing option individually against CTA. Exercise ECG testing without imaging is clearly less expensive than CTA, but PROMISE was not designed to prove that it was clinically equivalent or better. The lack of evidence of a difference in this case is not evidence of a lack of a difference. The recent SCOT-HEART (Scottish Computed Tomography of the Heart) trial reported that, after 1.7 years, CTA was associated with 38% fewer fatal and nonfatal myocardial infarctions than a usual care strategy based primarily on exercise ECG testing (3). Thus, we are not in a position to conclude that, had treadmill testing been used in all patients in PROMISE, the clinical outcomes would be unchanged or would favor treadmill testing alone. Squires and Anderson's analysis (4) provides a very low-powered view of country-level health care spending and outcomes that does not permit any conclusions about cause and effect. We do agree with Dr. Martin that the value of medical technology cannot be assumed and must be shown, which is why we conducted PROMISE.