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Editorial
June 3, 2020

Functional vs Anatomical Testing for Patients With Stable Chest Pain—Binary or Directional Thinking?

Author Affiliations
  • 1Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
JAMA Cardiol. Published online June 3, 2020. doi:10.1001/jamacardio.2020.1582

More than a decade ago, the National Heart, Lung, and Blood Institute sponsored a workshop on outcomes research in cardiovascular imaging that called for a shift in the research paradigm for cardiovascular testing from descriptions of test performance to randomized clinical trial research evaluating clinical outcomes.1 This paradigm shift has been associated with much current evidence about noninvasive testing for patients with stable chest pain, directly informing the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial2 and possibly the Scottish Computed Tomography of the Heart (SCOT-HEART) trial3 and other trials, but it also framed the question as binary: is functional testing or anatomical testing better? Although the question is simple and intuitive, it implies a win-lose conflict that need not exist and encourages clinicians and investigators to choose “sides.” The alternative to binary thinking is directional thinking, an inclusive approach that seeks to provide nuance rather than polarization, and sees research as an opportunity to learn and not as a chance to win.

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