Need For Invasive Coronary Angiography Research Articles

Enhancing pre-transplant cardiac assessment: Validation and utility of the CAD-LT score with CCTA in liver transplant candidates

BackgroundCoronary computed tomography angiography (CCTA) is increasingly being used in the preoperative workup for liver transplantation (LT). We sought to assess the utility of integrating CCTA with the novel CAD-LT (Coronary Artery Disease in Liver Transplantation) score and its impact on reducing the need for invasive coronary angiography prior to LT. MethodsWe conducted a retrospective cohort study of consecutive patients (age ≥ 18 years) who underwent CCTA for LT workup between 2011 and 2018 at the Victorian Liver Transplant Unit, Melbourne, Australia. CAD-LT scores, a traditional risk factor-based criteria, were calculated, and patients stratified as low-, intermediate- or high-risk. ResultsOverall, 229 patients underwent CCTA. The mean age was 66 ± 5 years (82% male) with a modest-to-high risk factor burden (diabetes, 53%; hypertension, 46%; current or former smoker, 62%). The mean CAD-LT score of our cohort was 12.4 ± 4.0. No patients were classified as low-risk, 49 patients (21.4%) were deemed intermediate-risk and 180 patients (78.6%) were deemed high-risk. A high CAD-LT score (≥ 9) showed high sensitivity (95.3% [95% CI 86–98%]) and modest specificity (27.8% [95% CI 21–35%]) for the detection of obstructive coronary artery disease on CCTA, with a negative predictive value of 94%. Following multidisciplinary discussions, only 41 patients (18%) of patients proceeded to ICA of which 27% received percutaneous coronary intervention. ConclusionsThe use of CCTA in patients deemed intermediate- to high-risk by the CAD-LT score has the potential to reduce the need for invasive coronary angiography in patients undergoing LT workup.

Coronary Computed Tomography Angiography Versus Invasive Coronary Angiography in Stable Chest Pain: A Meta-Analysis of Randomized Controlled Trials.

The efficacy of coronary computed tomography angiography (CCTA) versus invasive coronary angiography (ICA) among patients with stable chest pain has been studied in several trials with conflicting results. We performed a systematic review and meta-analysis comparing CCTA first versus direct ICA among patients with stable chest pain, who were initially referred to ICA. PubMed, EMBASE, and Cochrane Central were searched for randomized controlled trials comparing the 2 strategies. Risk ratios (RRs) and mean differences with 95% CIs were computed for binary and continuous outcomes, respectively. Five randomized controlled trials with a total of 5727 patients were included, of whom 51.1% were referred to CCTA and 22.5% of patients had evidence of ischemia on a prior functional test. In the follow-up ranging from 1 to 3.5 years, 660 of the 2928 patients randomized to CCTA first underwent ICA (23%). Patients who underwent CCTA had lower rates of coronary revascularization (RR, 0.74 [95% CI, 0.66-0.84]; P<0.001) and stroke (RR, 0.50 [95% CI, 0.26-0.98]; P=0.043). Cardiovascular mortality (RR, 0.55 [95% CI, 0.24-1.23]; P=0.146), major adverse cardiovascular events (RR, 0.84 [95% CI, 0.64-1.10]; P=0.198), nonfatal myocardial infarction (RR, 1.09 [95% CI, 0.63-1.88]; P=0.768), and cardiovascular hospitalizations (RR, 0.91 [95% CI, 0.59-1.39]; P=0.669) did not differ significantly between groups. In patients with stable chest pain referred for ICA, CCTA avoided the need for ICA in 77% of patients otherwise referred for ICA. CCTA was associated with a reduction in the rates of coronary revascularization and stroke compared with direct ICA. URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42023383143.

Role of cardiac imaging in acute chest pain.

Chest pain is the second most common complaint in the emergency department. The need to diagnose the cause of chest pain in a timely manner and appropriately direct care is crucial. This article discusses the role of imaging in acute chest pain, after first differentiating chest pain into cardiac and non-cardiac causes with upfront clinical and biochemical assessment. The role of non-invasive imaging including point-of-care ultrasound, echocardiography, myocardial perfusion imaging, cardiac MRI, coronary computed tomography angiography and novel cardiac CT applications are discussed. Updates in the literature regarding the role of coronary plaque imaging in acute chest pain are reviewed, as are ongoing challenges and future directions. This includes a discussion on the yield of diagnostic testing in low-risk acute chest pain cohorts vs intermediate-high risk cohorts. The incremental value of further testing in the former is low, which is reflected in contemporary guidelines that discourage the use of costly diagnostic tests in these cohorts. In the latter cohort, emerging evidence has shown specifically the role coronary computed tomography angiography could play in reducing the need for invasive coronary angiography in selective patients where the true probability of acute coronary syndrome is thought to be low. Real-world considerations such as accessibility and affordability are also discussed in the paper because while guidelines offer clinicians the flexibility of evidence-based choice, physician decision must necessarily be made in consideration of real-world constraints.

Relationship between the neutrophil to HDL-C ratio and anatomical significance of coronary artery stenosis in patients with documented myocardial ischemia.

Diagnostic workup of coronary artery disease (CAD) requires a stepwise approach, starting with detailed history-taking and ending with invasive coronary angiography (ICA) in some cases. The neutrophil to high-density lipoprotein cholesterol (HDL-C) ratio (NHR) is related to CAD. We assessed the association between the NHR and anatomical significance of coronary artery stenosis (CAS) in patients with documented ischemia. The study enrolled 306 consecutive patients with documented myocardial ischemia on myocardial perfusion imaging (MPI). All patients underwent ICA. Patients with no visible stenosis (NVS) or minimal or mild CAS were compared with those with moderate or severe CAS. The study compared 85 patients with NVS or minimal or mild CAS (46.51% female) and 221 patients with moderate or severe CAS (31.58% female). In the latter group, hypertension and diabetes mellitus (DM) were more prevalent than in the former group (83.73% vs. 60.47%, p<0.001; 47.37% vs. 30.23%, p=0.005, respectively). A higher NHR (cut-off point of 103.2) was associated with moderate or severe CAS. Even when myocardial ischemia is demonstrated by MPI, NVS or minimal or mild CAS is still frequently diagnosed based on ICA. A lower NHR could be an inexpensive, non-invasive marker of the need for ICA.

Combined cCTA and TAVR Planning for Ruling Out Significant CAD: Added Value of ML-Based CT-FFR

ObjectivesThe purpose of this study was to analyze the ability of machine-learning (ML)-based computed tomography (CT)-derived fractional flow reserve (CT-FFR) to further improve the diagnostic performance of coronary CT angiography (cCTA) for ruling out significant coronary artery disease (CAD) during pre-transcatheter aortic valve replacement (TAVR) evaluation in patients with a high pre-test probability for CAD. BackgroundCAD is a frequent comorbidity in patients undergoing TAVR. Current guidelines recommend its assessment before TAVR. If significant CAD can be excluded on cCTA, invasive coronary angiography (ICA) may be avoided. Although cCTA is a very sensitive test, it is limited by relatively low specificity and positive predictive value, particularly in high-risk patients. MethodsOverall, 460 patients (age 79.6 ± 7.4 years) undergoing pre-TAVR CT were included and examined with an electrocardiogram-gated CT scan of the heart and high-pitch scan of the vascular access route. Images were evaluated for significant CAD. Patients routinely underwent ICA (388/460), which was omitted at the discretion of the local Heart Team if CAD could be effectively ruled out on cCTA (72/460). CT examinations in which CAD could not be ruled out (CAD+) (n = 272) underwent additional ML-based CT-FFR. ResultsML-based CT-FFR was successfully performed in 79.4% (216/272) of all CAD+ patients and correctly reclassified 17 patients as CAD negative. CT-FFR was not feasible in 20.6% because of reduced image quality (37/56) or anatomic variants (19/56). Sensitivity, specificity, positive predictive value, and negative predictive value were 94.9%, 52.0%, 52.2%, and 94.9%, respectively. The additional evaluation with ML-based CT-FFR increased accuracy by Δ+3.4% (CAD+: Δ+6.0%) and raised the total number of examinations negative for CAD to 43.9% (202/460). ConclusionsML-based CT-FFR may further improve the diagnostic performance of cCTA by correctly reclassifying a considerable proportion of patients with morphological signs of obstructive CAD on cCTA during pre-TAVR evaluation. Thereby, CT-FFR has the potential to further reduce the need for ICA in this challenging elderly group of patients before TAVR.

Computed Tomography-Derived Fractional Flow Reserve for the Diagnosis of Coronary Artery Disease

&#x0D; Computed tomography-derived fractional flow reserve (CT-FFR) may predict coronary artery disease or flow-limiting stenosis in adult patients with stable chest pain better than coronary CT angiography alone, based on the relevant studies in 2 systematic reviews.&#x0D; CT-FFR is associated with a decreased need for invasive coronary angiography and revascularization in adult patients with stable chest pain, based on findings from 1 systematic review.&#x0D; In the US settings, CT-FFR was dominant (i.e., less costly and more effective) compared to stress testing for the evaluation of low-risk stable chest pain, based on findings from 1 cost-effectiveness study.&#x0D;

DEtection of ProxImal Coronary stenosis in the work-up for Transcatheter aortic valve implantation using CTA (from the DEPICT CTA collaboration)

ObjectivesComputed tomography angiography (CTA) is performed routinely in the work-up for transcatheter aortic valve implantation (TAVI), and could potentially replace invasive coronary angiography (ICA) to rule out left main (LM) and proximal coronary stenosis. The objectives were to assess the diagnostic yield and accuracy of pre-TAVI CTA to detect LM and proximal coronary stenosis of ≥ 50% and ≥ 70% diameter stenosis (DS).MethodsThe DEPICT CTA database consists of individual patient data from four studies with a retrospective design that analyzed the diagnostic accuracy of pre-TAVI CTA to detect coronary stenosis, as compared with ICA. Pooled data were used to assess diagnostic accuracy to detect coronary stenosis in the left main and the three proximal coronary segments on a per-patient and a per-segment level. We included 1060 patients (mean age: 81.5 years, 42.7% male).ResultsOn ICA, the prevalence of proximal stenosis was 29.0% (≥ 50% DS) and 15.7% (≥ 70% DS). Pre-TAVI CTA ruled out ≥ 50% DS in 51.6% of patients with a sensitivity of 96.4%, specificity of 71.2%, PPV of 57.7%, and NPV of 98.0%. For ≥ 70% DS, pre-TAVI CTA ruled out stenosis in 70.0% of patients with a sensitivity of 96.7%, specificity of 87.5%, PPV of 66.9%, and NPV of 99.0%.ConclusionCTA provides high diagnostic accuracy to rule out LM and proximal coronary stenosis in patients undergoing work-up for TAVI. Clinical application of CTA as a gatekeeper for ICA would reduce the need for ICA in 52% or 70% of patients, using a threshold of ≥ 50% or ≥ 70% DS, respectively.Key Points• Clinical application of CTA as a gatekeeper for ICA would reduce the need for ICA in 52% or 70% of TAVI patients, using a threshold of ≥ 50% or ≥ 70% diameter stenosis.• The diagnostic accuracy of CTA to exclude proximal coronary stenosis in these patients is high, with a sensitivity of 96.4% and NPV of 98.0% for a threshold of ≥ 50%, and a sensitivity of 96.7% and NPV of 99.0% for a threshold of ≥ 70% diameter stenosis.• Atrial fibrillation and heart rate did not significantly affect sensitivity and NPV. However, a heart rate of < 70 b/min during CTA was associated with a significantly improved specificity and PPV.

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

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.

Real world utilization of CT derived fractional flow reserve in stable angina from contemporary practice: impact on downstream utilization of invasive coronary angiogram and clinical decision making

Abstract Background/Introduction - Fractional flow reserve (FFR), a pressure wire-based index used during coronary angiography to assess the severity of potential coronary stenosis, is considered as the reference standard for evaluating the severity of stenosis in coronary artery disease (CAD). Recently, computed tomography angiography-derived fractional flow reserve (FFRct) has been recommended for evaluating functional severity of stenoses as it improves diagnostic accuracy and reduces the need for invasive coronary angiography. Purpose To determine whether non-invasive FFRct predicts severity of coronary artery disease and whether its addition improves efficiency of proceeding to revascularisation and invasive coronary angiography (ICA) compared to coronary computed tomography angiography (CTA) without FFR. Methods This observational retrospective single center study included two cohorts of patients who presented in a District General Hospital in UK. The first group consisted of all patients who underwent coronary CTA for chest pain from January 2013 to December 2014. The second cohort consisted of all patients who proceeded to have measurement of FFRct from April 2018 to June 2019 after routine coronary CTA for chest pain. The two groups showed similar demographics. FFRct was analysed using the software HeartFlow. We determined the agreement of FFRct (positive if &amp;lt;0.80) with stenosis on CTA and ICA (positive if &amp;gt;50% left main or &amp;gt;70% other coronary artery) and whether it correlated with need for revascularisation. We also assessed if adding FFRct &amp;lt;0.80 improved efficiency of referral to ICA, defined as decreased diagnosis of mild or moderate stenosis (&amp;lt;70%) and higher yield of severe disease (&amp;gt;70%). The two cohorts were compared to determine the above specific end-points. Results In the first cohort, data was collected for 915 patients. 240 (26.2%) of these patients proceeded to ICA, which showed severe disease in 31 (3.3%) patients needing revascularisation. In the second cohort of patients, 824 patients underwent coronary CTA and 201 (24.4%) proceeded to have FFRct measurements. 99 (49%) of these patients had a negative FFR and 65 (32%) patients had a positive result (&amp;lt;0.80). There was agreement between FFRct and invasive coronary angiography/stress echo in 44 (77%) patients, with regards to severity /revascularisation. The need for ICA was significantly reduced if coronary CTA and FFRct were both done (240/915; 26.2% vs 54/824; 6.5%: p value &amp;lt;0.00001). Conclusion Reserving ICA for patients with a positive FFRct (&amp;lt;0.80) could reduce the number of ICA after coronary CTA and augment the number of ICA leading to revascularisation. Use of FFRct as a gatekeeper to ICA will improve appropriate selection of patients referred and this in-turn will reduce the burden of complications associated with invasive procedures, reduce costs and ensure better utilization of Cath-lab resources. Funding Acknowledgement Type of funding source: None

Women With Spontaneous Coronary Artery Dissection Are at Increased Risk of Iatrogenic Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of acute coronary syndrome (ACS) that affects women disproportionately. Previous case series have found that patients with SCAD undergoing cardiac catheterisation have high rates of iatrogenic coronary damage. We formally compared the rate of iatrogenic coronary artery dissection in women with and without SCAD undergoing cardiac catheterisation over a 11-year period. Women with SCAD were identified by a search of the cardiac catheterisation database 2007-2017 for the keywords 'SCAD', 'spontaneous coronary artery dissection', 'spontaneous coronary dissection', and 'spontaneous dissection'. For each identified case, the medical record and the coronary angiogram images were reviewed to confirm spontaneous coronary dissection. For cases of recurrent SCAD, duplicates were removed so that each patient was included only once in this analysis. For each identified case of SCAD, a control case was chosen from women aged <70 years, without SCAD, undergoing cardiac catheterisation for an ACS during the same 10-year period. One control case was chosen to match each SCAD patient as closely as possible for age and year of cardiac catheterisation. Iatrogenic coronary dissection was defined as new, proximal, flow limiting coronary artery dissection in a different coronary segment to the presenting spontaneous coronary dissection. Eighty-five (85) cases of women with SCAD were identified. Mean age was not different between SCAD and non-SCAD women (51±11 and 51±10 years, respectively). The SCAD group had lower rates of ST elevation myocardial infarction, lower rises in serum creatine kinase (CK) and troponin levels, lower rates of diabetes and smoking, and far less placement of stents during the procedure than the control group. The rate of additional iatrogenic dissection relating to the cardiac catheterisation procedure was 4 of 85 (4.7%) versus 0 of 85 (0%), p=0.04 in SCAD and control groups, respectively, despite a much lower rate of percutaneous coronary intervention in the SCAD group. No common factors could be identified regarding particular equipment or procedural factors associated with iatrogenic dissection. The rate of iatrogenic dissection in women with SCAD during cardiac catheterisation is confirmed to be high and significantly higher than a contemporaneous age-matched group of women without SCAD. This observation likely indicates generalised coronary fragility in this disease, and emphasises the importance of the utmost care in the engagement, injection and intervention involving the coronary arteries in this disease. Development of a non-invasive coronary imaging modality or biomarker able to diagnose SCAD non-invasively would be a great advance in the care of patients with this condition, because it would avoid the need for invasive coronary angiography for diagnosis.

Low Rate of Invasive Coronary Angiography Following Transcatheter Aortic Valve Implantation: Real-World Prospective Cohort Findings

AimTo evaluate the real need for coronary access after transcatheter aortic valve implantation (TAVI). Methods and resultsProspective observational single-center registry, including 563 consecutive patients who underwent TAVI between April 2008 and November 2018, with both self- and balloon-expandable valves in a tertiary European center. Mean age was 82.4 ± 6.9 years, 53.3% were female, 16% had previous history of coronary artery bypass grafting, 33% of previous percutaneous coronary intervention (PCI), and 16.6% of myocardial infarction (MI). Twenty-four percent of the patients were revascularized within one year before TAVI in preparation for the procedure. Median Society of Thoracic Surgeons score was 4.82 (IQ 2.84).In a median follow-up of 24 months (IQ 21.5), 18 patients (3.2%) were identified as potentially in need for invasive coronary angiography: 9 (1.6%) in the setting of stable coronary artery disease and 9 (1.6%) for an acute coronary syndrome.A total of 11 PCIs were performed in 9 patients, with a complete success rate of 63.6%. Procedures that were unsuccessful or partially unsuccessful were due to the inability to cross the stent or the drug-eluting balloon through the valve struts or misplacement within the coronary artery due to lack of catheter support. ConclusionIn this population, a strategy of previous guideline-directed revascularization before TAVI was associated with a low rate of MI and repeated need of coronary access, with a scattered distribution over time. Assuring future access to coronary arteries in patients at increased risk may depend on the revascularization strategy rather than device selection.

Combined Coronary CT-Angiography and TAVI-Planning: A Contrast-Neutral Routine Approach for Ruling-out Significant Coronary Artery Disease.

Background: Significant coronary artery disease (CAD) is a common finding in patients undergoing transcatheter aortic valve implantation (TAVI). Assessment of CAD prior to TAVI is recommended by current guidelines and is mainly performed via invasive coronary angiography (ICA). In this study we analyzed the ability of coronary CT-angiography (cCTA) to rule out significant CAD (stenosis ≥ 50%) during routine pre-TAVI evaluation in patients with high pre-test probability for CAD. Methods: In total, 460 consecutive patients undergoing pre-TAVI CT (mean age 79.6 ± 7.4 years) were included. All patients were examined with a retrospectively ECG-gated CT-scan of the heart, followed by a high-pitch-scan of the vascular access route utilizing a single intravenous bolus of 70 mL iodinated contrast medium. Images were evaluated for image quality, calcifications, and significant CAD; CT-examinations in which CAD could not be ruled out were defined as positive (CAD+). Routinely, patients received ICA (388/460; 84.3%; Group A), which was omitted if renal function was impaired and CAD was ruled out on cCTA (Group B). Following TAVI, clinical events were documented during the hospital stay. Results: cCTA was negative for CAD in 40.2% (188/460). Sensitivity, specificity, PPV, and NPV in Group A were 97.8%, 45.2%, 49.6%, and 97.4%, respectively. Median coronary artery calcium score (CAC) was higher in CAD+-patients but did not have predictive value for correct classification of patients with cCTA. There were no significant differences in clinical events between Group A and B. Conclusion: cCTA can be incorporated into pre-TAVI CT-evaluation with no need for additional contrast medium. cCTA may exclude significant CAD in a relatively high percentage of these high-risk patients. Thereby, cCTA may have the potential to reduce the need for ICA and total amount of contrast medium applied, possibly making pre-procedural evaluation for TAVI safer and faster.

Temporal changes in FFRCT-Guided Management of Coronary Artery Disease – Lessons from the ADVANCE Registry

BackgroundThe ADVANCE registry is a large prospective study of outcomes and resource utilization in patients undergoing coronary computed tomography angiography (CCTA) and CT-based fractional flow reserve (FFRCT). As experience with new technologies and practices develops over time, we investigated temporal changes in the use of FFRCT within the ADVANCE registry. Methods5083 patients with coronary artery disease (CAD) on CCTA were prospectively enrolled in the ADVANCE registry and were divided into 3 equally sized cohorts based on the temporal order of enrollment per site. Demographics, CCTA and FFRCT findings, and clinical outcomes through 1-year follow-up, were recorded and compared between tertiles. ResultsThe number of patients with a ≥70% stenosis on CCTA was similar over time (33.6%, 30.9%, and 33.8% for cohort 1–3). The rate of positive FFRCT ≤0.80 was higher for cohorts 2 (67.3%) and 3 (74.6%) than for cohort 1 (57.1%, p < 0.001). Invasive FFR rates decreased from 25.8% to 22.4% between cohort 1 and 3 (p = 0.023). Moreover, patients with a FFRCT ≤0.80 were less frequently referred for invasive coronary angiography (ICA) (from 62.9% to 52.9%, p < 0.001), and underwent fewer revascularizations between cohort 1 and 3 (from 41.9% to 32.0%, p < 0.001). The prevalence of major events was low (1.2%) and similar between cohorts. ConclusionsGrowing experience with FFRCT improved the likelihood of identifying hemodynamically significant CAD and safely reduced the need for ICA and revascularization in patients with anatomically significant disease even in the instance of an abnormal FFRCT.

Fractional Flow Reserve Derived from Coronary Computed Tomography Angiography Safely Defers Invasive Coronary Angiography in Patients with Stable Coronary Artery Disease.

Objectives: In the United States, the real-world feasibility and outcome of using fractional flow reserve from coronary computed tomography angiography (FFRCT) is unknown. We sought to determine whether a strategy that combined coronary computed tomography angiography (CTA) and FFRCT could safely reduce the need for invasive coronary angiography (ICA), as compared to coronary CTA alone. Methods: The study included 387 consecutive patients with suspected CAD referred for coronary CTA with selective FFRCT and 44 control patients who underwent CTA alone. Lesions with 30–90% diameter stenoses were considered of indeterminate hemodynamic significance and underwent FFRCT. Nadir FFRCT ≤ 0.80 was positive. The rate of patients having ICA, revascularization and major adverse cardiac events were recorded. Results: Using coronary CTA and selective FFRCT, 121 patients (32%) had at least one vessel with ≥50% diameter stenosis; 67/121 (55%) patients had at least one vessel with FFRCT ≤ 0.80; 55/121 (45%) underwent ICA; and 34 were revascularized. The proportion of ICA patients undergoing revascularization was 62% (34 of 55). The number of patients with vessels with 30–50% diameter of stenosis was 90 (23%); 28/90 (31%) patients had at least one vessel with FFRCT ≤ 0.80; 8/90 (9%) underwent ICA; and five were revascularized. In our institutional practice, compared to coronary CTA alone, coronary CTA with selective FFRCT reduced the rates of ICA (45% vs. 80%) for those with obstructive CAD. Using coronary CTA with selective FFRCT, no major adverse cardiac events occurred over a mean follow-up of 440 days. Conclusion: FFRCT safely deferred ICA in patients with CAD of indeterminate hemodynamic significance. A high proportion of those who underwent ICA were revascularized.

Diagnostic accuracy of computed tomography angiography for the exclusion of coronary artery disease in candidates for transcatheter aortic valve implantation

Coronary CT angiography (CTA) is currently considered a reliable method to exclude obstructive coronary artery disease (CAD) before valvular heart surgery in patients with low pretest probability. However, its role in excluding obstructive CAD before transcatheter aortic valve implantation (TAVI) is less well established. Single-center retrospective study where patients with severe symptomatic aortic stenosis underwent both CTA and invasive coronary angiography (ICA) as part of TAVI planning. CTA exams were conducted on a 64-slice dual source scanner, with a median interval of 45 days to ICA (IQR 25–75 [13–82]). In both tests, obstructive CAD was defined as a ≥50% stenosis in an epicardial vessel ≥2 mm diameter. Per-patient, per-vessel and per-proximal segment analyses were conducted, excluding and including non-evaluable segments. The study included 200 patients (120 women, mean age 83 ± 6 years). The prevalence of obstructive CAD on ICA was 35.5% (n = 71). On a per-patient analysis (assuming non-evaluable segments as stenotic), CTA showed sensitivity of 100% (95% CI, 95–100%), specificity of 42% (95% CI, 33–51%), and positive and negative predictive values of 48% (95% CI, 44–51%) and 100% (95% CI, 92–100%), respectively. CTA was able to exclude obstructive CAD in 54 patients (27%), in whom ICA could have been safely withheld. Despite the high rate of inconclusive tests, pre-procedural CTA is able to safely exclude obstructive CAD in a significant proportion of patients undergoing TAVI, possibly avoiding the need for ICA in roughly one quarter of the cases.

Assessment of lesion-specific ischemia using fractional flow reserve (FFR) profiles derived from coronary computed tomography angiography (FFRCT) and invasive pressure measurements (FFRINV): Importance of the site of measurement and implications for patient referral for invasive coronary angiography and percutaneous coronary intervention

BackgroundFractional flow reserve (FFR)-derived from computed tomography angiography (CTA; FFRCT) and invasive FFR (FFRINV) are used to assess the need for invasive coronary angiography (ICA) and percutaneous coronary intervention (PCI). The optimal location for measuring FFR and the impact of measurement location have not been well defined. Methods930 patients (age 60.7 + 10 years, 59% male) were included in this study. Normal and diseased coronary arteries were classified into stenosis grades 0–4 in the left anterior descending artery (LAD, n = 518), left circumflex (LCX, n = 112) and right coronary artery (RCA, n = 585). FFRCT (n = 1215 arteries) and FFRINV (n = 26 LAD) profiles were developed by plotting FFR values (y-axis) versus site of measurement (x-axis: ostium, proximal, mid, distal segments). The best location to measure FFR was defined relative to the distal end of the stenosis. FFR ≤0.8 was considered positive for ischemia. ResultsIn normal and stenotic coronary arteries there are significant declines in FFRCT and FFRINV from the ostium to the distal vessel (p < 0.001), due to lesion-specific ischemia and to effects unrelated to the lesion. A reliable location (distal to the stenosis) is 10.5 mm [IQR 7.3–14.8 mm] for FFRCT and within 20–30 mm for FFRINV. Rates of positive FFR (from the distal vessel) reclassified to negative FFR (distal to the stenosis) are 61% (FFRCT) and 33% (FFRINV). ConclusionFFRCT and FFRINV values are influenced by stenosis severity and the site of measurement. FFR measurements from the distal vessel may over-estimate lesion-specific ischemia and result in unnecessary referrals for ICA and PCI.

TCT-578 Assessment of Lesion-Specific Ischemia Using Fractional Flow Reserve (FFR) Profiles Derived from Coronary Computed Tomography Angiography (FFRCT) and Invasive Measurements (FFRINV): Importance of the Site of Measurement and Implications for Patient Referral for Invasive Coronary Angiography

Fractional flow reserve (FFR)-derived from computed tomography angiography (CTA; FFRCT) and invasive FFR (FFRINV) are used to assess the need for invasive coronary angiography (ICA) and percutaneous coronary intervention (PCI). The optimal location for measuring FFR and the impact of measurement

Outcomes of non-invasive diagnostic modalities for the detection of coronary artery disease: network meta-analysis of diagnostic randomised controlled trials

ObjectiveTo evaluate differences in downstream testing, coronary revascularisation, and clinical outcomes following non-invasive diagnostic modalities used to detect coronary artery disease.DesignSystematic review and network meta-analysis.Data sourcesMedline, Medline in process, Embase,...

Non rate-controlled CT coronary angiography for the exclusion of obstructive coronary artery disease in the assessment of patients referred for transcatheter aortic valve implantation

Purpose: Optimal management of concomitant coronary artery disease (CAD) in patients undergoing transcatheter aortic valve implantation (TAVI) is contentious. This study aimed to assess the role of routine non rate-controlled CT coronary angiography (CTCA) in assessing CAD in patients referred for TAVI, thereby potentially precluding the need for invasive coronary angiography (ICA). CTCA in this cohort can be difficult due to the high burden of coronary calcium and the inability to perform standard pharmacological rate control. Methods: All patients underwent an ECG-gated 128-slice calcium score and CT angiogram to assess peripheral vasculature, aortic anatomy, aortic valve calcification and location of the coronary ostia. Coronary artery calcium scores (CACS) and CTCA images were scored by two independent, blinded observers and compared with ICA performed prior to TAVI. Significant coronary stenosis was defined as ≥70% and ICA was deemed the gold standard for true disease status. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated for CTCA at a patient level. Results: 70 consecutive patients referred for consideration of TAVI were studied: 40% male (n=28), mean age 78.9yrs (±7.91), 23% diabetic (n=16). Significant CAD was demonstrated in 30% of ICA studies (1 vessel disease (VD) 20% [n=14], 2VD 8.6% [n=6], 3VD 1.4% [n=1]). The sensitivity, specificity, PPV and NPV of CTCA for the detection of significant coronary stenoses were 57.9% (CI: 33.5% to 79.7%), 87.0% (CI: 75.1% to 94.6%), 61.1% (CI: 35.8% to 82.6%) and 85.4% (CI: 73.3% to 93.5%) respectively. The vast majority of false positive (5/6; 83%) and false negative (6/7; 86%) CTCAs were seen in patients in the highest quartile of CACS (>400). Conclusions: In patients undergoing CT assessment prior to TAVI, non rate-controlled CTCA shows poor sensitivity but good specificity and negative predictive value for the detection of significant CAD. A CAC score >400 may represent a threshold above which invasive angiography is mandated.

Diagnostic Accuracy and Clinical Utility of Noninvasive Testing for Coronary Artery Disease

In this observational study, the authors aimed to define the clinical utility of stress testing vs. computed tomography coronary angiography (CTCA) in determining the need for invasive coronary angiography (ICA). Although the diagnostic accuracy of CTCA has repeatedly been shown to supercede that of stress testing, the question of which patients need CTCA has not been definitively shown. In this study, 517 patients referred by their treating physicians received both stress testing and CTCA. CTCA was the most clinically useful in populations with intermediate (defined as 20–80%) pretest probability.