Detection of relevant extracardiac findings on coronary computed tomography angiography vs. invasive coronary angiography

Dominik Laskowski,Matthias Rief,Benjamin Kendziora,Sarah Feger,Henryk Dreger,Marc Dewey,Mahmoud Mohamed,Melanie Estrella,Elke Zimmermann,Maria Bosserdt

doi:10.1007/s00330-021-07967-x

Abstract

ObjectivesTo compare the detection of relevant extracardiac findings (ECFs) on coronary computed tomography angiography (CTA) and invasive coronary angiography (ICA) and evaluate the potential clinical benefit of their detection.MethodsThis is the prespecified subanalysis of ECFs in patients presenting with a clinical indication for ICA based on atypical angina and suspected coronary artery disease (CAD) included in the prospective single-center randomized controlled Coronary Artery Disease Management (CAD-Man) study. ECFs requiring immediate therapy and/or further workup including additional imaging were defined as clinically relevant. We evaluated the scope of ECFs in 329 patients and analyzed the potential clinical benefit of their detection.ResultsECFs were detected in 107 of 329 patients (32.5%; CTA: 101/167, 60.5%; ICA: 6/162, 3.7%; p < .001). Fifty-nine patients had clinically relevant ECFs (17.9%; CTA: 55/167, 32.9%; ICA: 4/162, 2.5%; p < .001). In the CTA group, ECFs potentially explained atypical chest pain in 13 of 101 patients with ECFs (12.9%). After initiation of therapy, chest pain improved in 4 (4.0%) and resolved in 7 patients (6.9%). Follow-up imaging was recommended in 33 (10.0%; CTA: 30/167, 18.0%; ICA: 3/162, 1.9%) and additional clinic consultation in 26 patients (7.9%; CTA: 25/167, 15.0%; ICA: 1/162, 0.6%). Malignancy was newly diagnosed in one patient (0.3%; CTA: 1/167, 0.6%; ICA: 0).ConclusionsIn this randomized study, CTA but not ICA detected clinically relevant ECFs that may point to possible other causes of chest pain in patients without CAD. Thus, CTA might preclude the need for ICA in those patients.Trial registrationNCT Unique ID: 00844220Key Points• CTA detects ten times more clinically relevant ECFs than ICA.• Actionable clinically relevant ECFs affect patient management and therapy and may thus improve chest pain.• Detection of ECFs explaining chest pain on CTA might preclude the need for performing ICA.

Highlights

Coronary computed tomography angiography (CTA) and invasive coronary angiography (ICA) are both well-established methods for the assessment of cardiac and coronary anatomyEur Radiol and pathology
Seventy-nine clinically relevant extracardiac findings (ECFs) were detected in 59 patients (59/329, 17.9%; CTA: 55/167, 32.9%; ICA: 4/162, 2.5%)
Details of the distribution and frequencies of ECFs by group (CTA versus ICA) and anatomy are given in ESM Table 2

Summary

Introduction

Coronary computed tomography angiography (CTA) and invasive coronary angiography (ICA) are both well-established methods for the assessment of cardiac and coronary anatomyEur Radiol and pathology. CTA is a radiological, noninvasive technique whereas ICA is a cardiological, invasive method. Detailed evaluation of adjacent anatomy allows identification of extracardiac findings (ECFs) which may potentially explain the patient’s symptoms or require further workup and therapy. This may be especially important for patients in whom cardiac pathologies have been ruled out, but chest pain still persists. Patients in whom CTA rules out CAD while simultaneously detecting ECFs explaining chest pain might be spared an ICA. We found only one study on the follow-up assessment of ECFs in patients with chest pain. Some of the ECFs were identified as treatable causes of the patients’ chest pain [2]

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