CCTA to guide revascularization for high-risk CAD: a 'cliff hanger'

Abstract

This editorial refers to ‘All-cause mortality benefit of coronary revascularization vs. medical therapy in patients without known coronary artery disease undergoing computed tomographic angiography: results from CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter Registry)’, by J.K. Min et al. , doi:10.1093/eurheartj/ehs315 From its inception in 1958, invasive coronary angiography (ICA) has been the sole key imaging technique to diagnose coronary obstructions and to guide revascularization, initially by bypass graft surgery (CABG), and later by balloon angioplasty and stent implantation. However, ICA comes at a price, with, inherent to the invasive nature of the procedure, patient inconvenience, complications (albeit low), and costs. To contain referral to ICA, clinicans consider the pre-test probability of obstructive coronary artery disease (CAD) and employ non-invasive stress tests to assess provocable myocardial ischaemia as a gatekeeper to ICA. The pre-test probability can be estimated using algorithms based on age, gender, symptom characteristics, traditional risk factors of cardiovascular disease, and the resting electrocardiogram (ECG). Numerous non-invasive stress tests are available to assess the presence and functional severity of CAD, which is associated with clinical outcome, and guide further decision making. Patients without evidence of stress-induced myocardial ischaemia have an excellent prognosis and generally do not need further testing. Patients with minimal to moderate ischaemia may initially be treated medically, reserving ICA for those with symptoms refractory to optimal medical therapy. Patients with severe ischaemia are usually directly referred for ICA to determine suitability for revascularization with percutaneous coronary intervention (PCI) or CABG. Numerous studies have convincingly shown that revascularization of high-risk angiographic CAD is associated with better clinical outcome than medical therapy.1 Angiographic high-risk CAD is defined as two-vessel disease (VD) involving the left anterior descending (LAD), three-VD, or left main. However, current guidelines …