Physicians' Academy for Cardiovascular Education

CT vs. invasive coronary angiography in stable chest pain: Same MACE risk but less complications

CT or Invasive Coronary Angiography in Stable Chest Pain

Literature - The DISCHARGE Trial Group - N Engl J Med. 2022 Apr 28;386:1591-602. doi: 10.1056/NEJMoa2200963

Introduction and methods


Invasive coronary angiography (ICA) is the reference standard to diagnose obstructive coronary artery disease (CAD) and enables coronary revascularization during the same procedure. However, elective ICA is associated with rare but major procedure-related complications [1]. CT is an accurate, noninvasive alternative to ICA in patients with stable chest pain and intermediate pretest probability of obstructive CAD [2,3].

Aim of the study

The aim of this study was to compare CT with ICA as initial diagnostic imaging strategy for guiding treatment of patients with stable chest pain who were clinically referred for ICA.


The DISCHARGE (Diagnostic Imaging Strategies for Patients with Stable Chest Pain and Intermediate Risk of Coronary Artery Disease) trial was a multicenter, pragmatic, randomized, assessor-blinded, parallel-group, superiority trial, in which 3667 patients were randomly assigned (1:1 ratio) to CT or ICA. Inclusion criteria were: age ≥30 years, referral for ICA because of stable chest pain, and intermediate pretest probability of obstructive CAD (10%–60%). Patients were recruited at one of 26 certified clinical centers in 16 European countries.


The primary outcome was MACE, a composite of CV death, nonfatal MI, and nonfatal stroke. An expanded primary outcome—a composite of CV death, nonfatal MI, nonfatal stroke, TIA, and major procedure-related complications—was also assessed.

Key secondary outcomes were major procedure-related complications occurring during or within 48 hours of CT/ICA, related tests, or revascularization procedures, and patient-reported outcomes (including angina pectoris during the last 4 weeks of follow-up, and health-related quality of life measured with the EQ-5D and SF-12v2).

Main results

Primary outcome

Secondary outcomes


Among patients referred for ICA because of stable chest pain and intermediate pretest probability of obstructive CAD, there were no differences in MACE risk, incidence of angina, or quality of life between the group that was assigned to CT as the initial diagnostic imaging strategy and the group that underwent ICA. However, the frequencies of major procedure-related complications and revascularization procedures were lower with an initial CT strategy.


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Find this article online at N Engl J Med.

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