Although one might hypothesize, as the investigators do, that due to its combination of high diagnostic accuracy and improved prognostication, cCTA could become the first-line test of suspected CAD, it is important to take a deeper look at the study findings to determine what benefits would be achieved by this approach. The dominant contributor to future MACEs in the study was coronary revascularization (most of which was percutaneous coronary intervention), which accounted for >80% of all MACEs. Although coronary revascularization was only included in MACEs if it occurred >90 days after the index test, the confounding effect of cCTA driving the study endpoints cannot be ignored, because >60% of coronary revascularizations were for lesions deemed to be obstructive at the index cCTA. Although percutaneous coronary intervention for stable CAD provides excellent control of angina, it has not been shown to reduce the rate of future death or myocardial infarction (11); therefore, any benefit of a cCTA-first approach would be mostly limited to the improved identification of those in whom intervention might provide a symptomatic benefit. The rate of “hard” CAD endpoints, such as death, myocardial infarction, or unstable angina, in patients with a negative XECG was extremely low, with only 6 such events in nearly 2,500 patients during the follow-up period. There are many other aspects that would require clarification before elevating cCTA to the first-line test for suspected CAD, most notably the competing role of functional modalities, such as perfusion imaging and stress echocardiography versus anatomic imaging, the potential harm of radiation, and also cost efficacy.