Vaccine against Pneumococcal Pneumonia in Adults

The authors reply: Our study was a pragmatic comparative-effectiveness trial evaluating functional testing versus coronary CTA in patients with stable chest pain and, as such, reflects actual care provided across its 193 North American sites.Each study site met current standards for imaging quality and was certified in all techniques.However, it is likely that testing at some sites reflects better available practices than at others.Whereas Bom et al. correctly point out that expert sites may use lower doses of radiation in performing CTA than were recorded for some patients in our study, this is also true for nuclear testing.Pragmatic design principles also governed the selection of the type of functional test, which was at the discretion of the local care team.Although we did not record the appropriateness of testing according to technique, all patients were symptomatic and middle-aged or older, and more than 97% had at least one cardiovascular risk factor.Stress testing with the use of any technique is generally considered to be appropriate in such patients.We agree with Martin that many features of exercise stress testing predict the risk of death, and in our study, we compared the effect of all the information derived from testing on outcomes.Stratification of randomization according to the intended diagnostic test allowed for a comparison of outcomes in the approximately 1100 patients (a reasonably large cohort) who were assigned to undergo either exercise ECG or CTA, and the two strategies were found to be equivalent.Blumenthal and Wasfy correctly point out that