Computed Tomography or Functional Stress Testing for the Prediction of Risk: Can I Have My Cake and Eat It?

The clinician now has an overwhelming array of investigations at their disposal for patients with suspected coronary heart disease. These tests are used to diagnose or to risk stratify patients, and thereby enable the clinician to treat their symptoms and to reduce their future risk. Ultimately, these investigations assess either risk factors (such as lipid, glucose and c-reactive protein concentrations) and proxies for disease (such as carotid intima-media thickness and coronary artery calcium score), or they are looking to provide circumstantial downstream evidence of disease (such as markers of ischemia and infarction: Q waves on an electrocardiogram, fibrosis on magnetic resonance imaging or functional stress testing). In this issue of Circulation, Budoff and colleagues compare two of the most widely used approaches, coronary artery calcium scoring and functional stress testing, within the framework of the PROspective Multicenter Imaging Study for Evaluation of chest pain (PROMISE) trial.