BACKGROUND Many patients have symptoms suggestive of coronary artery disease (CAD) and are often evaluated with the use of diagnostic testing, although there are limited data from randomized trials to guide care. METHODS We randomly assigned 10,003 symptomatic patients to a strategy of initial anatomical testing with the use of coronary computed tomographic angiography (CTA) or to functional testing (exercise electrocardiography, nuclear stress testing, or stress echocardiography). The composite primary end point was death, myocardial infarction, hospitalization for unstable angina, or major procedural complication. Secondary end points included invasive cardiac catheterization that did not show obstructive CAD and radiation exposure. RESULTS The mean age of the patients was 60.8±8.3 years, 52.7% were women, and 87.7% had chest pain or dyspnea on exertion. The mean pretest likelihood of obstructive CAD was 53.3±21.4%. Over a median follow-up period of 25 months, a primary end-point event occurred in 164 of 4996 patients in the CTA group (3.3%) and in 151 of 5007 (3.0%) in the functional-testing group (adjusted hazard ratio, 1.04; 95% confidence interval, 0.83 to 1.29; P = 0.75). CTA was associated with fewer catheterizations showing no obstructive CAD than was functional testing (3.4% vs. 4.3%, P = 0.02), although more patients in the CTA group underwent catheterization within 90 days after randomization (12.2% vs. 8.1%). The median cumulative radiation exposure per patient was lower in the CTA group than in the functional-testing group (10.0 mSv vs. 11.3 mSv), but 32.6% of the patients in the functional-testing group had no exposure, so the overall exposure was higher in the CTA group (mean, 12.0 mSv vs. 10.1 mSv; P<0.001). CONCLUSIONS In symptomatic patients with suspected CAD who required noninvasive testing, a strategy of initial CTA, as compared with functional testing, did not improve clinical outcomes over a median follow-up of 2 years. (Funded by the National Heart, Lung, and Blood Institute; PROMISE ClinicalTrials.gov number, NCT01174550.)

/pdf/outcomes-of-anatomical-versus-functional-testing-for-ycven9jugs.pdf

Outcomes of Anatomical versus Functional Testing for Coronary Artery Disease

Background: 
Although coronary computed tomographic angiography (CTA) improves diagnostic certainty in the assessment of patients with stable chest pain, its effect on 5-year clinical outcomes is unknown.

Methods: 
In an open-label, multicenter, parallel-group trial, we randomly assigned 4146 patients with stable chest pain who had been referred to a cardiology clinic for evaluation to standard care plus CTA (2073 patients) or to standard care alone (2073 patients). Investigations, treatments, and clinical outcomes were assessed over 3 to 7 years of follow-up. The primary end point was death from coronary heart disease or nonfatal myocardial infarction at 5 years.

Results: 
The median duration of follow-up was 4.8 years, which yielded 20,254 patient-years of follow-up. The 5-year rate of the primary end point was lower in the CTA group than in the standard-care group (2.3% [48 patients] vs. 3.9% [81 patients]; hazard ratio, 0.59; 95% confidence interval [CI], 0.41 to 0.84; P=0.004). Although the rates of invasive coronary angiography and coronary revascularization were higher in the CTA group than in the standard-care group in the first few months of follow-up, overall rates were similar at 5 years: invasive coronary angiography was performed in 491 patients in the CTA group and in 502 patients in the standard-care group (hazard ratio, 1.00; 95% CI, 0.88 to 1.13), and coronary revascularization was performed in 279 patients in the CTA group and in 267 in the standard-care group (hazard ratio, 1.07; 95% CI, 0.91 to 1.27). However, more preventive therapies were initiated in patients in the CTA group (odds ratio, 1.40; 95% CI, 1.19 to 1.65), as were more antianginal therapies (odds ratio, 1.27; 95% CI, 1.05 to 1.54). There were no significant between-group differences in the rates of cardiovascular or noncardiovascular deaths or deaths from any cause.

Conclusions: 
In this trial, the use of CTA in addition to standard care in patients with stable chest pain resulted in a significantly lower rate of death from coronary heart disease or nonfatal myocardial infarction at 5 years than standard care alone, without resulting in a significantly higher rate of coronary angiography or coronary revascularization. (Funded by the Scottish Government Chief Scientist Office and others; SCOT-HEART ClinicalTrials.gov number, NCT01149590).

/pdf/coronary-ct-angiography-and-5-year-risk-of-myocardial-6ejqigv030.pdf

Coronary CT Angiography and 5-Year Risk of Myocardial Infarction.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)60291-4.pdf

CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicentre trial

Non-invasive detection of coronary inflammation using computed tomography and prediction of residual cardiovascular risk (the CRISP CT study): a post-hoc analysis of prospective outcome data

https://ora.ox.ac.uk/objects/uuid:e0b5ae23-d562-4348-94b8-84f70b7812c5/download_file?safe_filename=Cipriani%2520et%2520al%2C%2520Comparative%2520efficacy%2520and%2520tolerability%2520of%2520antidepressants%2520for%2520major%2520depression%2520in%2520ch.pdf&file_format=application%2Fpdf&type_of_work=Journal+article

Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis.

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Chest pain of recent onset: assessment and diagnosis

#### The bottom line

Irritable bowel syndrome (IBS) is a chronic gastrointestinal disorder with an estimated prevalence of 10-20%.1 The condition mostly affects people aged 20-30 years and is twice as common in women as in men.1 It can be painful and debilitating, lead to feelings of anxiety and depression, and negatively affect quality of life.1

This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE) on irritable bowel syndrome in adults in primary care.2

NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. Where the evidence was minimal, recommendations in the original guidance were based on the guideline development group’s experience and opinion of what constitutes good practice. Changes in this update are based on evidence from updated systematic reviews and updated evidence on cost effectiveness. Evidence levels for the recommendations are given in italic in square brackets.

### Initial assessment

Irritable bowel syndrome in adults in primary care: summary of updated NICE guidance

This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.

https://www.bmj.com/content/bmj/350/bmj.h824.full.pdf

Diagnosis and management of depression in children and young people: summary of updated NICE guidance

Hypothermia: prevention and management in adults having surgery

https://onlinelibrary.wiley.com/doi/pdf/10.1111/1753-6405.12925

Paul Crosland

Papers

Chest pain of recent onset: assessment and diagnosis

Irritable bowel syndrome in adults in primary care: summary of updated NICE guidance

Diagnosis and management of depression in children and young people: summary of updated NICE guidance

Hypothermia: prevention and management in adults having surgery

The economic cost of preventable disease in Australia: a systematic review of estimates and methods