Abstract
This study aimed to determine the impact of systematic coronary computed tomographic angiography (CCTA) use following an abnormal non-invasive ischemia test (NIST) on patient selection strategy for invasive coronary angiography (ICA).In patients with suspected stable coronary artery disease (CAD), NIST use frequently results in sub-optimal diagnostic and revascularization yields of ICA.This randomized clinical trial, conducted at a single academic tertiary center, selected 220 symptomatic patients with mild-to-moderately abnormal NIST results who were referred for ICA. Patients received either the originally intended ICA (n = 105) or CCTA (n = 115). The primary endpoint was the diagnostic yield of ICA in each group. Revascularization yield and major adverse cardiovascular events at 12 months were also assessed.The patients were 69 ± 9 years old, 60% were men, and 31% had typical angina. Mean pre-test probability of obstructive CAD was 34%. Overall prevalence of obstructive CAD was 37.7% on the index angiographic procedure. In the CCTA group, ICA was cancelled by referring physicians in 83 patients (72.2%) after receiving CCTA results. For those undergoing ICA, diagnostic (84.4% vs. 41.7%, p<0.001) and revascularization (71.9% vs. 38.8%, p = 0.001) yields were significantly higher for CCTA-guided ICA than for standard NIST-guided ICA. Mean cumulative radiation exposure was significantly lower in the CCTA-guided ICA arm than in the NIST-guided ICA arm (12 ± 9 vs. 16 ± 10 mSv, respectively, p = 0.024). There were no significant differences in the primary safety endpoint rates between the strategies (p = 0.439).In patients with suspected CAD and mild-to-moderately abnormal ischemia tests, a diagnostic strategy including CCTA as a gatekeeper is safe and effective and significantly improves diagnostic and revascularization yields of ICA.
Highlights
With the progressive increase in the population at risk for coronary artery disease (CAD), health systems are under considerable logistical and financial pressures to offer efficient methods of risk stratification, diagnosis, and therapy [1]
This study aimed to determine the impact of systematic coronary computed tomographic angiography (CCTA) use following an abnormal non-invasive ischemia test (NIST) on patient selection strategy for invasive coronary angiography (ICA)
In the CCTA group, ICA was cancelled by referring physicians in 83 patients (72.2%) after receiving CCTA results
Summary
With the progressive increase in the population at risk for coronary artery disease (CAD), health systems are under considerable logistical and financial pressures to offer efficient methods of risk stratification, diagnosis, and therapy [1]. Current international guidelines recommend direct referrals to invasive coronary angiography (ICA) in patients with a high clinical likelihood of CAD and the use of non-invasive testing to select intermediate-risk patients who may need ICA [2]. This patient selection strategy based on alternative functional or anatomic testing may result in sub-optimal diagnostic performance of ICA [3]. Coronary computed tomographic angiography (CCTA) is an excellent method to non-invasively exclude obstructive CAD and has been included in diagnostic algorithms as an alternative to non-invasive ischemia tests (NIST) [7, 8] – Fig. 1. In patients with suspected stable coronary artery disease (CAD), NIST use frequently results in suboptimal diagnostic and revascularization yields of ICA
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