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Background  The optimal initial noninvasive diagnostic testing strategy for stable coronary artery disease ( CAD ) is unknown. Although American guidelines recommend an exercise stress test as the first‐line test, European guidelines suggest that stress imaging (myocardial perfusion imaging or stress echocardiography) or coronary computed tomography angiography may be preferable. Understanding the relationship between the initial strategy and downstream yield of obstructive  CAD  and major adverse cardiac events may provide insight as to the optimal strategy.    Methods and Results  We conducted a population‐based retrospective cohort study of adults in Ontario, Canada, using health administrative and clinical data. The relationship between the initial testing strategy and obstructive  CAD  on invasive angiography was examined. Patients were then followed from their angiogram onward to determine whether they developed a composite end point of  major adverse cardiac events . After adjusting for covariates, patients with initial  myocardial perfusion imaging  (odds ratio: 0.92; 95%  confidence interval,  0.85, 1.00),  coronary computed tomography angiography  ( odds ratio:  1.51; 95%  confidence interval,  0.91, 2.49), or stress echo ( odds ratio:  0.95; 95%  confidence interval,  0.84, 1.08) did not a have significantly different yield of obstructive  CAD  compared with those with an initial  exercise stress test . Furthermore, there was no significant difference in downstream  major adverse cardiac events  after invasive angiography among the 4 initial testing strategies after adjusting for clinically relevant covariates.    Conclusions  Our study found no evidence to suggest significant differences in either yield of obstructive  CAD  or downstream  major adverse cardiac events  in patients undergoing an initial noninvasive testing strategy with stress or anatomical imaging compared with those undergoing an initial  exercise stress test .

journal of the american heart association

Comparison of Anatomic and Clinical Outcomes in Patients Undergoing Alternative Initial Noninvasive Testing Strategies for the Diagnosis of Stable Coronary Artery Disease