Non-invasive computed tomography coronary angiography as a gatekeeper for invasive coronary angiography

Fleur R De Graaf,Greetje J De Grooth,Allard Sieders,Lucia J Kroft,Joanne D Schuijf,Albert De Roos,Stephanie M De Boer,Joëlla E Van Velzen,Jeroen J Bax,Jacob M Van Werkhoven,J Wouter Jukema,Ernst E Van Der Wall,Martin J Schalij

doi:10.1007/s10554-012-0059-8

Abstract

To determine the rate of subsequent invasive coronary angiography (ICA) and revascularization in relation to computed tomography coronary angiography (CTA) results. In addition, independent determinants of subsequent ICA and revascularization were evaluated. CTA studies were performed using a 64-row (n = 413) or 320-row (n = 224) multidetector scanner. The presence and severity of CAD were determined on CTA. Following CTA, patients were followed up for 1 year for the occurrence of ICA and revascularization. A total of 637 patients (296 male, 56 ± 12 years) were enrolled and 578 CTA investigations were available for analysis. In patients with significant CAD on CTA, subsequent ICA rate was 76 %. Among patients with non-significant CAD on CTA, subsequent ICA rate was 20 % and among patients with normal CTA results, subsequent ICA rate was 5.7 % (p < 0.001). Of patients with significant CAD on CTA, revascularization rate was 47 %, as compared to a revascularization rate of 0.6 % in patients with non-significant CAD on CTA and no revascularizations in patients with a normal CTA results (p < 0.001). Significant CAD on CTA and significant three-vessel or left main disease on CTA were identified as the strongest independent predictors of ICA and revascularization. CTA results are strong and independent determinants of subsequent ICA and revascularization. Consequently, CTA has the potential to serve as a gatekeeper for ICA to identify patients who are most likely to benefit from revascularization and exclude patients who can safely avoid ICA.

Highlights

Invasive coronary angiography (ICA) is routinely used for the identification of patients with suspected coronary artery disease (CAD)
CTA has the potential to serve as a gatekeeper for invasive coronary angiography (ICA) to identify patients who are most likely to benefit from revascularization and exclude patients who can safely avoid ICA
Multivariate logistic regression analysis for ICA was performed to determine the independent association with significant CAD on CTA and significant three-vessel or left main disease on CTA, each corrected for clinical baseline variables in a separate model

Summary

Introduction

Invasive coronary angiography (ICA) is routinely used for the identification of patients with suspected coronary artery disease (CAD). Advantages of ICA are high resolution imaging and the possibility of revascularization by percutaneous coronary intervention (PCI). The rate of normal ICA examinations is still quite high and health-care costs associated with the increase in ICA and revascularization rates are substantial. A non-invasive test to select the most suitable patients for ICA and revascularization would be preferable. With the introduction of computed tomography coronary angiography (CTA), the non-invasive anatomic assessment of CAD with high diagnostic accuracy has become possible. CTA cannot replace ICA, this technique could serve as a gatekeeper for ICA in selected patients, and avoid unnecessary additional examinations. The purpose of the present study was to determine the rate of subsequent ICA and revascularization in relation to CTA results. Independent determinants of subsequent ICA and revascularization were investigated

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