Coronary Computed Tomography Angiography Testing Research Articles

Coronary Atherosclerosis Across the Glycemic Spectrum Among Asymptomatic Adults: The Miami Heart Study at Baptist Health South Florida.

The contemporary burden and characteristics of coronary atherosclerosis, assessed using coronary computed tomography angiography (CCTA), is unknown among asymptomatic adults with diabetes and prediabetes in the United States. The pooled cohort equations and coronary artery calcium (CAC) score stratify atherosclerotic cardiovascular disease risk, but their association with CCTA findings across glycemic categories is not well established. Asymptomatic adults without atherosclerotic cardiovascular disease enrolled in the Miami Heart Study were included. Participants underwent CAC and CCTA testing and were classified into glycemic categories. Prevalence of coronary atherosclerosis (any plaque, noncalcified plaque, plaque with ≥1 high-risk feature, maximal stenosis ≥50%) assessed by CCTA was described across glycemic categories and further stratified by pooled cohort equations-estimated atherosclerotic cardiovascular disease risk and CAC score. Adjusted logistic regression was used to evaluate the associations between glycemic categories and coronary outcomes. Among 2352 participants (49.5% women), the prevalence of euglycemia, prediabetes, and diabetes was 63%, 30%, and 7%, respectively. Coronary plaque was more commonly present across worsening glycemic categories (euglycemia, 43%; prediabetes, 58%; diabetes, 69%), and similar pattern was observed for other coronary outcomes. In adjusted analyses, compared with euglycemia, prediabetes and diabetes were each associated with higher odds of any coronary plaque (OR, 1.30 [95% CI, 1.05-1.60] and 1.75 [1.17-2.61], respectively), noncalcified plaque (OR, 1.47 [1.19-1.81] and 1.99 [1.38-2.87], respectively), and plaque with ≥1 high-risk feature (OR, 1.65 [1.14-2.39] and 2.53 [1.48-4.33], respectively). Diabetes was associated with stenosis ≥50% (OR, 3.01 [1.79-5.08]; reference=euglycemia). Among participants with diabetes and estimated atherosclerotic cardiovascular disease risk <5%, 46% had coronary plaque and 10% had stenosis ≥50%. Among participants with diabetes and CAC=0, 30% had coronary plaque and 3% had stenosis ≥50%. Among asymptomatic adults, worse glycemic status is associated with higher prevalence and extent of coronary atherosclerosis, high-risk plaque, and stenosis. In diabetes, CAC was more closely associated with CCTA findings and informative in a larger population than the pooled cohort equations.

Implementation of High-Sensitivity Cardiac Troponin Assays in the United States

BackgroundFew data exist regarding the implementation of high-sensitivity cardiac troponin (hs-cTn) assays in the United States since their approval. ObjectivesThis study sought to explore trends in hs-cTn assay implementation over time and assess the association of their use with in-hospital cardiac testing and outcomes. MethodsThe study examined trends in implementation of hs-cTn assays among participating hospitals in the National Cardiovascular Data Registry Chest Pain-MI [Myocardial Infarction] Registry from January 1, 2019 through September 30, 2021. Associations among hs-cTn use, use of in-hospital diagnostic imaging, and patient outcomes were assessed using generalized estimating equation models with logistic or gamma distributions. ResultsAmong 550 participating hospitals (N = 251,000), implementation of hs-cTn assays increased from 3.3% in the first quarter of 2019 to 32.6% in the third quarter of 2021 (Ptrend < 0.001). Use of hs-cTn was associated with more echocardiography among persons with non–ST-segment elevation acute coronary syndrome (NSTE-ACS; 82.4% vs 75.0%; adjusted odds ratio: 1.43; 95% CI: 1.19-1.73) but not among low-risk chest pain individuals. Use of hs-cTn was associated with less invasive coronary angiography among low-risk patients (3.7% vs 4.5%; adjusted odds ratio: 0.73; 95% CI: 0.58-0.92) but similar use for patients with NSTE-ACS. There was no association between hs-cTn use and noninvasive stress testing or coronary computed tomography angiography testing. Among individuals with NSTE-ACS, hs-cTn use was not associated with revascularization or in-hospital mortality. Use of hs-cTn was associated with a shorter length of stay (median 47.6 hours vs 48.0 hours; ratio: 0.94; 95% CI: 0.90-0.98). ConclusionsImplementation of hs-cTn among U.S. hospitals is increasing, but most U.S. hospitals continue to use less sensitive assays. The use of hs-cTn was associated with modestly shorter length of stay, greater use of echocardiography for NSTE-ACS, and less use of invasive angiography among low-risk patients.

Coronary computed tomography angiography vs functional testing for stable coronary artery disease: long-term outcomes meta-analysis

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND The emerging role of coronary computed tomography angiography (CCTA) has been acknowledged in the 2019 Guidelines of the European Society of Cardiology recommending it’s as the initial diagnostic strategy for most patients with suspected stable coronary artery disease (CAD). However, it is unclear how CCTA performs compared with the standard approach of functional testing (FT). We performed an updated meta-analysis to clarify the question, analyzing outcomes beyond one year of follow-up. METHODS We searched PubMed for studies comparing clinical outcomes with ≥1 year of follow-up between initial CCTA vs FT strategy in patients with suspected stable CAD. Occurrence of all-cause mortality and non-fatal acute coronary syndrome (ACS) was the combined primary outcome. Secondary outcomes included non-fatal myocardial infarction (MI), the use of longer-term investigations, revascularization procedures and new medication use. RESULTS A total of 29,579 patients underwent either CCTA (n = 14,457) or FT (n = 15,122) and were followed for a mean of 1.75 years. CCTA was associated with a comparable all-cause mortality and non-fatal ACS to FT (2.64% vs 2.65%; risk ratio [RR], 0.97; 95% CI, 0.76-1.22). However, a 41% reduction in non-fatal MI was evident after CCTA testing (RR 0.59, 95% CI 0.41-0.83; P = 0.003). Compared with FT, patients undergoing CCTA were less likely to downstream additional testing (28.85% vs 33.86%; odds ratio [OR], 0.47, 95%CI 0.21-1.01; P = 0.05) and more prone to pursue coronary revascularization (OR 1.72; 95%CI 1.11-2.66; P = 0.01). Significant heterogeneity for invasive coronary angiography and revascularization was noted. CCTA patients had a non significant increase in new medication use, namely aspirin or statin therapy. CONCLUSIONS In patients with suspected stable CAD, initial evaluation with CCTA was associated with a long-term 41% decrease in non-fatal MI and 53% reduction in downstream testing. Despite these differences, CCTA strategy was associated with a similar risk of long-term all-cause mortality and non-fatal ACS. Abstract Figure.

Impact of non-invasive anatomical testing on optimal medical prescription in patients with suspected coronary artery disease.

Compared to functional testing, coronary computed tomography angiography (CTA) improves clinical outcomes in patients with suspected coronary artery disease (CAD). This is thought to be the result of an increased prescription of preventive medical therapy (statins and aspirin) when relying on a CTA imaging strategy. We compared the rate of statins prescription in a patient cohort assessed either with coronary CTA or exercise testing, and evaluated the agreement on medication prescriptions. Consecutive patients who underwent coronary CTA and exercise test for suspected CAD were included. Four clinical cardiologists independently analysed each case based on clinical information and the result of either coronary CTA or exercise test. For each case, treatment strategy and prescription were recorded while blinded to the results of the other cardiac test. Treatment strategy was reassessed using the alternative imaging modality three weeks after the first evaluation. A total of 113 patients were included. Mean age was 56.7±11.5 years, 52% were males and diabetes were present in 6%. Coronary CTA showed an obstructive epicardial stenosis in 21.4% and any type of atherosclerotic plaque in 54.2%. Functional testing identified ischemia in 9.1%. The use of coronary CTA resulted in higher number of statin (64.9% vs. 44.5%, P<0.001) and aspirin (21.4% vs. 4.3%, P<0.001) prescriptions. There was a substantial agreement on the prescription of statins (mean Cohen's κ coefficient of 0.79±0.07). Epicardial atherosclerotic disease was found in half of patients with suspected CAD as assessed by coronary CTA. Compared to functional testing, coronary CTA evaluation by coronary was associated with an increase in the rate preventive therapy prescription.

Coronary CT Angiographic and Flow Reserve-Guided Management of Patients With Stable Ischemic Heart Disease

BackgroundClinical outcomes following coronary computed tomography–derived fractional flow reserve (FFRCT) testing in clinical practice are unknown. ObjectivesThis study sought to assess real-world clinical outcomes following a diagnostic strategy including first-line coronary computed tomography angiography (CTA) with selective FFRCT testing. MethodsThe study reviewed the results of 3,674 consecutive patients with stable chest pain evaluated with CTA and FFRCT testing to guide downstream management in patients with intermediate stenosis (30% to 70%). The composite endpoint (all-cause death, myocardial infarction, hospitalization for unstable angina, and unplanned revascularization) was determined in 4 patient groups: 1) CTA stenosis <30%, optimal medical treatment (OMT), and no additional testing; 2) FFRCT >0.80, OMT, no additional testing; 3) FFRCT ≤0.80, OMT, no additional testing; and 4) FFRCT ≤0.80, OMT, and referral to invasive coronary angiography. Patients were followed for a median of 24 (range 8 to 41) months. ResultsFFRCT was available in 677 patients, and the test result was negative (>0.80) in 410 (61%) patients. In 75% of the patients with FFRCT >0.80, maximum coronary stenosis was ≥50%. The cumulative incidence proportion (95% confidence interval [CI]) of the composite endpoint at the end of follow-up was comparable in groups 1 (2.8%; 95% CI: 1.4% to 4.9%) and 2 (3.9%; 95% CI: 2.0% to 6.9%) (p = 0.58) but was higher (when compared with group 1) in groups 3 (9.4%; p = 0.04) and 4 (6.6%; p = 0.08). Risk of myocardial infarction was lower in group 4 (1.3%) than in group 3 (8%; p < 0.001). ConclusionsIn patients with intermediate-range coronary stenosis, FFRCT is effective in differentiating patients who do not require further diagnostic testing or intervention (FFRCT >0.80) from higher-risk patients (FFRCT ≤0.80) in whom further testing with invasive coronary angiography and possibly intervention may be needed. Further studies assessing the risk and optimal management strategy in patients undergoing first-line CTA with selective FFRCT testing are needed.

Prognostic Value of Risk Factors, Calcium Score, Coronary CTA, Myocardial Perfusion Imaging, and Invasive Coronary Angiography in Kidney Transplantation Candidates

ObjectivesThis study sought to perform a prospective head-to-head comparison of the predictive value of clinical risk factors and a variety of cardiac imaging modalities including coronary artery calcium score (CACS), coronary computed tomography angiography (CTA), single-photon emission computed tomography (SPECT), and invasive coronary angiography (ICA) on major adverse cardiac events (MACE) and all-cause mortality in kidney transplantation candidates. BackgroundCurrent guidelines recommend screening for coronary artery disease in kidney transplantation candidates. Furthermore, noninvasive stress imaging is recommended in current guidelines, despite its low diagnostic accuracy and uncertain prognostic value. MethodsThe study prospectively evaluated 154 patients referred for kidney transplantation. All patients underwent CACS, coronary CTA, SPECT, and ICA testing. The clinical endpoints were extracted from patients’ interviews, patients’ records, and registries. ResultsThe mean follow-up time was 3.7 years. In total, 27 (17.5%) patients experienced MACE, and 31 (20.1%) patients died during follow-up. In a time-to-event analysis, both risk factors and CACS significantly predicted death, but only CACS predicted MACE. Combining risk factors with CACS identified a very-low-risk cohort with a MACE event rate of 2.1%, and a 1.0% mortality rate per year. Of the diagnostic modalities, coronary CTA and ICA significantly predicted MACE, but only coronary CTA predicted death. In contrast, SPECT predicted neither MACE nor death. ConclusionsCompared with traditional risk factors and other cardiac imaging modalities, CACS and coronary CTA seem superior for risk stratification in kidney transplant candidates. Applying a combination of risk factors and CACS and subsequently coronary CTA seems to be the most appropriate strategy. (Angiographic CT of Renal Transplantation Candidate Study [ACToR]; NCT01344434)

Plasma biomarker levels and non-obstructive coronary artery disease determined by coronary computed tomography angiography.

Coronary computed tomography angiography (CTA) and several circulating biomarkers have prognostic value regarding cardiovascular disease (CVD) events, but their association is incompletely studied. We aimed to investigate whether markers of lipid metabolism, inflammation and kidney function could predict non-obstructive coronary artery disease (CAD) determined by coronary CTA, in a low-to-intermediate-risk group. Coronary CTA and laboratory testing were performed for 115 subjects (45-70years), with low prevalence of CVD risk factors, predominantly low-to-intermediate Framingham risk and normal or mildly reduced kidney function. Forty-nine (43%) had no CAD at coronary CTA, and 66 (57%) had CAD in ≥1 segment (stenosis<50%). Adiponectin was inversely associated with CAD, and lipoprotein(a) and cystatin C were associated with CAD at coronary CTA. In multivariable logistic regression, cystatin C remained an independent predictor of CAD (OR: 2·50, 95% CI: 1·12-5·59). Cystatin C also correlated to the number of diseased segments (rs =0·25, P<0·01). Higher plasma levels of cystatin C were associated with non-obstructive CAD at coronary CTA in subjects with low-to-intermediate CVD risk and normal to mildly reduced kidney function.

Reduction in Observation Unit Length of Stay With Coronary Computed Tomography Angiography Depends on Time of Emergency Department Presentation

Prior studies demonstrating shorter length of stay (LOS) from coronary computed tomography angiography (CCTA) relative to stress testing in emergency department (ED) patients have not considered time of patient presentation. The objectives of this study were to determine whether low-risk chest pain patients receiving stress testing or CCTA have differences in ED plus observation unit (OU) LOS and if there are disparities in testing modality use, based on the time of patient presentation to the ED. The authors examined a cohort of low-risk chest pain patients evaluated in an ED-based OU using prospective and retrospective OU registry data. During the study period, stress testing and CCTA were both available from 08:00 to 17:00 hours. CCTA was not available on weekends, and therefore only subjects presenting on weekdays were included. Cox regression analysis was used to model the effect of testing modality (stress testing vs. CCTA) on OU LOS. Separate models were fit based on time of patient presentation to the ED using 4-hour blocks beginning at midnight. The primary independent variable was testing modality: stress testing or CCTA. Age, sex, and race were included as covariates. Logistic regression was used to model testing modality choice by time period adjusted for age, sex, and race. Over the study period, 841 subjects presented Monday through Friday. Median LOS was 18.0 hours (interquartile range [IQR] = 11.7 to 22.9 hours). Objective cardiac testing was completed in 788 of 841 (94%) patients, with 496 (63%) receiving stress testing and 292 (37%) receiving CCTA. After age, race, and sex were adjusted for, patients presenting between 08:00 and 11:59 hours not only had a shorter LOS associated with CCTA (p < 0.0001), but also had a greater likelihood of being tested by CCTA (p = 0.001). None of the other time periods had significant differences in LOS or testing modality choice for CCTA relative to stress testing. In an OU setting with weekday and standard business hours CCTA availability, CCTA testing was associated with shorter LOS among low-risk chest pain patients only in patients presenting to the ED between 08:00 and 11:59 hours. That time period was also associated with a greater likelihood of being tested by CCTA, suggesting that ED providers may have intuited the inability of CCTA to shorten LOS during other times.

The Prognostic Significance of Coronary CT Angiography

Coronary computed tomography angiography (CTA) is an increasingly utilized, highly accurate noninvasive test for the diagnosis of coronary artery disease. Accumulating data have convincingly demonstrated that the presence, extent, and location of both obstructive and nonobstructive coronary atherosclerosis visualized on coronary CTA conveys powerful prognostic information, incremental to that provided by clinical variables and coronary calcium scoring. Proposed markers of future plaque instability and coronary risk, such as the degree of vessel remodeling and low-attenuation plaque volume, as well as measures of CT myocardial perfusion, may further improve the prognostic value of CTA. Ultimately, studies are needed to assess whether the prognostic information provided by coronary CTA testing results in sustained changes in patient and provider behaviors that cost effectively improve patient outcomes.