Use Of Invasive Coronary Angiography Research Articles

Site-level variability in the processes of care and outcomes over time among patients with COVID-19 and myocardial injury: Insights from the American Heart Association's COVID-19 Cardiovascular Disease Registry

BackgroundElevated cardiac troponin (cTn) levels in patients with COVID-19 has been associated with worse outcomes. Guidelines on best practices of those patients remain uncertain. MethodsWe included patients with COVID-19 and cTn above the assay-specific upper limit of normal (ULN) enrolled in the American Heart Association's COVID-19 registry between March 2020–January 2021. Site-level variability in invasive coronary angiography, LVEF assessment, ICU utilization, and inpatient mortality were determined by calculating adjusted median odds ratio (MOR) using hierarchical logistic regression models. Temporal trends were assessed with Cochran-Armitage trend test. ResultsAmong 32,636 patients, we included 6234 (19.4 %) with cTn above ULN (age 68.7 ± 16.0 years, 56.5 % male, 51.5 % Caucasian), of whom 1365 (21.6 %) had ≥5-fold elevations. Across 55 sites, the median rate of invasive coronary angiography was 0.1 % with adjusted MOR 1.5(1.0,2.3), median LVEF assessment was 25.5 %, MOR 3.0(2.2,3.9), ICU utilization was 41.7 %, MOR 2.2(1.8,2.6), and mortality was 20.9 %, MOR 1.7(1.5,2.0). Over time, we noted a significant increase in invasive coronary angiography (p-trend = 0.001), and LVEF assessment (p-trend<0.001), and reduction in mortality (p-trend<0.001), without significant change in ICU admissions (p-trend = 0.08). Similar variability and temporal trends were seen among patients with ≥5-fold cTn elevation. ConclusionsThe use of invasive coronary angiography among patients with COVID-19 and myocardial injury was very low during the early pandemic. We found moderate institutional variability in processes of care with an uptrend in invasive catheterization and LVEF assessment, and downtrend in mortality. Comparative effectiveness studies are needed to examine whether variability in care is associated with differences in outcomes.

Early computed tomography coronary angiography in adults presenting with suspected acute coronary syndrome: the RAPID-CTCA RCT.

Acute coronary syndrome is a common medical emergency. The optimal strategy to investigate patients who are at intermediate risk of acute coronary syndrome has not been fully determined. To investigate the role of early computed tomography coronary angiography in the investigation and treatment of adults presenting with suspected acute coronary syndrome. A prospective, multicentre, open, parallel-group randomised controlled trial with blinded end-point adjudication. Thirty-seven hospitals in the UK. Adults (aged ≥ 18 years) presenting to the emergency department, acute medicine services or cardiology department with suspected or provisionally diagnosed acute coronary syndrome and at least one of the following: (1) a prior history of coronary artery disease, (2) a cardiac troponin level > 99th centile and (3) an abnormal 12-lead electrocardiogram. Early computed tomography coronary angiography in addition to standard care was compared with standard care alone. Participants were followed up for 1 year. One-year all-cause death or subsequent type 1 (spontaneous) or type 4b (stent thrombosis) myocardial infarction, measured as the time to such event adjudicated by two cardiologists blinded to the computerised tomography coronary angiography ( CTCA ) arm. Cost-effectiveness was estimated as the lifetime incremental cost per quality-adjusted life-year gained. Between 23 March 2015 and 27 June 2019, 1748 participants [mean age 62 years (standard deviation 13 years), 64% male, mean Global Registry Of Acute Coronary Events score 115 (standard deviation 35)] were randomised to receive early computed tomography coronary angiography (n = 877) or standard care alone (n = 871). The primary end point occurred in 51 (5.8%) participants randomised to receive computed tomography coronary angiography and 53 (6.1%) participants randomised to receive standard care (adjusted hazard ratio 0.91, 95% confidence interval 0.62 to 1.35; p = 0.65). Computed tomography coronary angiography was associated with a reduced use of invasive coronary angiography (adjusted hazard ratio 0.81, 95% confidence interval 0.72 to 0.92; p = 0.001) but no change in coronary revascularisation (adjusted hazard ratio 1.03, 95% confidence interval 0.87 to 1.21; p = 0.76), acute coronary syndrome therapies (adjusted odds ratio 1.06, 95% confidence interval 0.85 to 1.32; p = 0.63) or preventative therapies on discharge (adjusted odds ratio 1.07, 95% confidence interval 0.87 to 1.32; p = 0.52). Early computed tomography coronary angiography was associated with longer hospitalisations (median increase 0.21 days, 95% confidence interval 0.05 to 0.40 days) and higher mean total health-care costs over 1 year (£561 more per patient) than standard care. The principal limitation of the trial was the slower than anticipated recruitment, leading to a revised sample size, and the requirement to compromise and accept a larger relative effect size estimate for the trial intervention. The potential role of computed tomography coronary angiography in selected patients with a low probability of obstructive coronary artery disease (intermediate or mildly elevated level of troponin) or who have limited access to invasive cardiac catheterisation facilities needs further prospective evaluation. In patients with suspected or provisionally diagnosed acute coronary syndrome, computed tomography coronary angiography did not alter overall coronary therapeutic interventions or 1-year clinical outcomes, but it did increase the length of hospital stay and health-care costs. These findings do not support the routine use of early computed tomography coronary angiography in intermediate-risk patients with acute chest pain. This trial is registered as ISRCTN19102565 and Clinical Trials NCT02284191. This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 37. See the NIHR Journals Library website for further project information.

Cancer patients with acute coronary syndrome have non-superior bleeding risk compared to patients with similar characteristics – a propensity score analysis from the ProACS registry

IntroductionThe management of acute coronary syndrome (ACS) in malignancy is challenging due to higher bleeding risk. MethodsWe analyzed patients with cancer (active or in the previous five years) prospectively included in the ProACS registry between 2010 and 2019. Our aim was to assess safety (major bleeding, primary endpoint) and secondary efficacy endpoints (in-hospital mortality and combined in-hospital mortality, reinfarction and ischemic stroke) of ACS treatment. Propensity score matching analysis (1:1) was further performed to better understand predictors of outcomes. ResultsWe found 934 (5%) cancer patients out of a total of 18 845 patients with ACS. Cancer patients had more events: major bleeding (2.9% vs. 1.5%), in-hospital mortality (5.8% vs. 3.4%) and the combined endpoint (7.4% vs. 4.9%). The primary endpoint was related to cancer diagnosis (OR 1.97), previous bleeding (OR 7.09), hemoglobin level (OR 4.94), atrial fibrillation (OR 3.50), oral anticoagulation (OR 3.67) and renal dysfunction. Mortality and the combined secondary endpoint were associated with lower use of invasive coronary angiography and antiplatelet and neurohormonal blocker therapy. After propensity score matching (350 patients), there were no statistically significant differences in endpoints between the populations. ConclusionBleeding risk was not significant higher in the cancer population compared to patients with similar characteristics, nor were mortality or ischemic risk. The presence of cancer should not preclude simultaneous ACS treatment.

Fractional flow reserve derived from computed tomography coronary angiography in the assessment and management of stable chest pain: the FORECAST randomized trial

Aims Fractional flow reserve (FFRCT) using computed tomography coronary angiography (CTCA) determines both the presence of coronary artery disease and vessel-specific ischaemia. We tested whether an evaluation strategy based on FFRCT would improve economic and clinical outcomes compared with standard care.Methods and results Overall, 1400 patients with stable chest pain in 11 centres were randomized to initial testing with CTCA with selective FFRCT (experimental group) or standard clinical care pathways (standard group). The primary endpoint was total cardiac costs at 9 months. Secondary endpoints were angina status, quality of life, major adverse cardiac and cerebrovascular events, and use of invasive coronary angiography. Randomized groups were similar at baseline. Most patients had an initial CTCA: 439 (63%) in the standard group vs. 674 (96%) in the experimental group, 254 of whom (38%) underwent FFRCT. Mean total cardiac costs were higher by £114 (+8%) in the experimental group, with a 95% confidence interval from −£112 (−8%) to +£337 (+23%), though the difference was not significant (P = 0.10). Major adverse cardiac and cerebrovascular events did not differ significantly (10.2% in the experimental group vs. 10.6% in the standard group) and angina and quality of life improved to a similar degree over follow-up in both randomized groups. Invasive angiography was reduced significantly in the experimental group (19% vs. 25%, P = 0.01).Conclusion A strategy of CTCA with selective FFRCT in patients with stable angina did not differ significantly from standard clinical care pathways in cost or clinical outcomes, but did reduce the use of invasive coronary angiography.

Invasive Coronary Angiography after Chest Pain Presentations to Emergency Departments.

We investigated patients presenting to emergency departments (EDs) with chest pain to identify factors that influence the use of invasive coronary angiography (ICA). Using linked ED, hospitalisations, death and cardiac biomarker data, we identified people aged 20 years and over who presented with chest pain to tertiary public hospital EDs in Western Australia from 1 January 2016 to 31 March 2017 (ED chest pain cohort). We report patient characteristics, ED discharge diagnosis, pathways to ICA, ICA within 90 days, troponin test results, and gender differences. Associations were examined with the Pearson Chi-squared test and multivariate logistic regression. There were 16,974 people in the ED chest pain cohort, with a mean age of 55.6 years and 50.7% males, accounting for 20,131 ED presentations. Acute coronary syndrome was the ED discharge diagnosis in 10.4% of presentations. ED pathways were: discharged home (57.5%); hospitalisation (41.7%); interhospital transfer (0.4%); and died in ED (0.03%)/inpatients (0.3%). There were 1546 (9.1%) ICAs performed within 90 days of the first ED chest pain visit, of which 59 visits (3.8%) had no troponin tests and 565 visits (36.6%) had normal troponin. ICAs were performed in more men than women (12.3% vs. 6.1%, p < 0.0001; adjusted OR 1.89, 95% CI 1.65, 2.18), and mostly within 7 days. Equal numbers of males and females present with chest pain to tertiary hospital EDs, but men are twice as likely to get ICA. Over one-third of ICAs occur in those with normal troponin levels, indicating that further investigation is required to determine risk profile, outcomes and cost effectiveness.

Evaluation of Guideline Adherence for Cardiac Catheterization in Patients With Presumed Obstructive Coronary Artery Disease in Germany (ENLIGHT-KHK) – A Multicentre, Prospective, Observational Study

IntroductionThe diagnosis or exclusion of obstructive stable coronary artery disease (SCAD) in clinical practice is challenging and therefore clinical guidelines provide recommendations on the use of non-invasive and invasive testing. For Germany, data obtained from the OECD and health insurances indicate a potential non-adherence to guideline-recommended diagnostic pathways. However, there is a lack of prospective and reliable evidence for appropriate use of invasive coronary angiography (CA) in Germany. ObjectiveTo provide evidence on the nature and extent of guideline non-adherence in patients undergoing CA with presumed obstructive SCAD in Germany and, to evaluate the clinical and economic consequences of potential deviations in guideline adherence. MethodsENLIGHT-KHK is a multicentre, prospective observational study recruiting 1500 patients being admitted for CA with presumed obstructive SCAD and exclusion of acute myocardial infarction (DRKS00015638). The primary outcome measure is the adherence to clinical guidelines in the decision-making process for use of CA. Therefore, the patients' diagnostic pathways and adherence to German and European guidelines will be assessed using clinical data, health-claims data, and a patient questionnaire. The primary safety outcome is a composite of myocardial infarction, stroke and all-cause death. Secondary outcome measures are periprocedural complications and costs. Using a decision-analytic model, the clinical and economic impact of observed guideline adherence in clinical practice will be assessed. Potential barriers and facilitators of guideline-adherent decision-making will be evaluated via semi-structured interviews. ConclusionsENLIGHT-KHK will give insights into the appropriateness of invasive CA in Germany and enable the development of concepts to improve guideline-adherence in the German health-care setting.

Implementation of coronary computed tomography angiography as nationally recommended first-line test in patients with suspected chronic coronary syndrome: impact on the use of invasive coronary angiography and revascularization.

To investigate the impact of applying coronary computed tomography angiography (CCTA), as the recommended first-line diagnostic test in patients with suspected chronic coronary syndrome (CCS) on the use of invasive coronary angiography (ICA) and revascularization practice. We included all patients undergoing a first-time CCTA (n = 53555) and first-time ICA (n = 41451) from 2008 to 2017 due to suspected CCS in Western Denmark (3.3 million inhabitants). The number of CCTA procedures increased from 352 (2008) to 7739 (2017) (2098%), ICA examinations declined from 4538 to 3766 (17%). The average proportion of no- or non-obstructive coronary artery disease by CCTA was 77.5%. Referral to ICA after CCTA occurred in 16.9% of patients in 2008-10 vs. 13.9% in 2014-17 (P < 0.0001). Revascularization in patients referred to ICA after CCTA increased from 33.8% in 2008-10 vs. 44.4% in 2014-17 (P < 0.0001). The revascularization proportion in patients undergoing ICA with no preceding CCTA was 32.3% in 2008-10 vs. 33.3% in (2014-17) (P = 0.1063). Stratified by age, the overall revascularization proportion increased in the younger age groups and was unchanged or decreased in older age groups: <50 years: 60% increase, 50-59 years: 33% increase, 60-69 years: 0%, and >70 years: 9.5% decrease. The introduction of CCTA as a first-line diagnostic test in patients with suspected CCS does not associate with increased use of invasive angiography and seems to have facilitated a more appropriate revascularization practice.

Trends in the Use of Cardiac Imaging for Patients With Heart Failure in Canada

Cardiac imaging is a component of the provision of medical care for patients with heart failure that has experienced a broad expansion in past decades. However, there is a paucity of studies examining the patterns of use of cardiac imaging modalities in real-world clinical practice. To investigate temporal trends in the use and costs of cardiac imaging for the examination of patients with heart failure in Canada and to examine the association between the institution of an accreditation program and the use of echocardiography. A repeated cross-sectional study based on population-based administrative databases in Ontario, Canada, of individuals with heart failure identified using a validated algorithm based on hospital admissions and ambulatory physician claims was conducted between April 1, 2002, and March 31, 2017. The incidence and prevalence of heart failure and the age- and sex-adjusted rate of use and costs of cardiac imaging, including resting and stress echocardiography, myocardial perfusion scintigraphy, invasive coronary angiography, computed tomography, magnetic resonance imaging, and positron emission tomography. A total of 882 355 adults (50.1% women; median age, 76 years [interquartile range, 66-83 years]) with prevalent heart failure were identified. The age- and sex-standardized prevalence of heart failure remained stable during the study (2.4% [95% CI, 2.4%-2.4%] in 2002 and 2.0% [95% CI, 2.0%-2.0%] in 2016). There was an increase in the rate of use of resting echocardiography, from 386 tests (95% CI, 373-398) per 1000 patients with heart failure in 2002 to 533 (95% CI, 519-547) per 1000 patients in 2011. Coinciding with the initiation of an accreditation program for echocardiography in 2012, there was an immediate reduction in the rate of use (-59.5 tests per 1000 patients with heart failure; P < .001), which was followed by a plateau in subsequent years. At the same time, there was a 10.8% relative reduction in the use of myocardial perfusion scintigraphy and an 11.2% relative reduction in the use of invasive coronary angiography from 2011 to 2016 and the incorporation of newer modalities after they became publicly insured health services. These findings suggest that resting echocardiography remains the most used imaging technique for patients with heart failure, exceeding the use of and the cost spent on other modalities. Stabilization in the use of traditional imaging modalities coincided temporally with the emergence of advanced techniques and provincewide quality improvement policy initiatives.

What is the Optimal Rate of Invasive Coronary Angiography After Acute Coronary Syndrome? - An ANZACS-QI Substudy

Background: Wide variability in the use of invasive coronary angiography in acute coronary syndromes (ACS) has been previously documented. Our aim was to investigate whether coronary angiography is being used appropriately after ACS, taking into account relative contraindications of the procedure. Method: Patients presenting with ACS in 2015 to two New Zealand (NZ) District Health Boards (DHBs) – Counties Manukau (CMDHB) and Waitemata (WDHB) - were identified from the NZ Ministry of Health National Dataset using ICD-10-AM codes. Patient data were obtained from the electronic and paper clinical records. Pre-defined relative contraindications to coronary angiography were identified. Results: Of the 3,809 patient admissions coded with ACS, 600 (300 from each DHB) were reviewed. 61 (10%) did not meet diagnostic criteria for ACS on review of clinical data and were excluded. Of the patients reviewed, 55% received coronary angiography, with a higher rate in WDHB than CMDHB (61% and 49%, respectively). The overall rate of angiography was appropriately high in those without a relative contraindication (90.3%) and low in those with one (7.4%). There were fewer patients with relative contraindications in WDHB than CMDHB (36.7% and 48.5%) but the rate of angiography in those without (92.5% and 87.5%) contraindications in the two DHBs was similar. Conclusion: Approximately 60% of patients had no documented relative contraindication suggesting that this may be an appropriate angiography rate in New Zealand practice. Differences between the two DHBs of around 10% appear to be clinically appropriate due to variation in contraindication rates.

Comparison of mid- to long-term clinical outcomes between anatomical testing and usual care in patients with suspected coronary artery disease: A meta-analysis of randomized trials.

Controversies remain regarding clinical outcomes following initial strategies of coronary computed tomography angiography (CCTA) vs usual care with functional testing in patients with suspected coronary artery disease (CAD). CCTA as initial diagnostic strategy results in better mid- to long-term outcomes than usual care in patients with suspected CAD. We searched PubMed, Embase, and Cochrane Library for randomized controlled trials comparing clinical outcomes during ≥6 months' follow-up between initial anatomical testing by CCTA vs usual care with functional testing in patients with suspected CAD. Occurrence of all-cause mortality, nonfatal myocardial infarction (MI), and major adverse cardiovascular events (MACE), and use of invasive coronary angiography and coronary revascularization, were compared between the 2 diagnostic strategies. Twelve trials were included (20 014 patients; mean follow-up, 20.5 months). Patients undergoing CCTA as initial noninvasive testing had lower risk of nonfatal MI compared with those treated with usual care (risk ratio [RR]: 0.70, 95% confidence interval [CI]: 0.52-0.94, P = 0.02). There was a tendency for reduced MACE following initial CCTA strategy, but not for risk of all-cause mortality. Compared with functional testing, the CCTA strategy increased use of invasive coronary angiography (RR: 1.53, 95% CI: 1.12-2.09, P = 0.007) and coronary revascularization (RR: 1.49, 95% CI: 1.11-2.00, P = 0.007). Anatomical testing with CCTA as the initial noninvasive diagnostic modality in patients with suspected CAD resulted in lower risk of nonfatal MI than usual care with functional testing, at the expense of more frequent use of invasive procedures.

Physician-level variation in the diagnosis of myocardial infarction and the use of angiography among Veterans with elevated troponin.

BackgroundCardiac troponin assays have improved the ability to detect myocardial damage. However, ascertaining whether troponin elevation is due to myocardial infarction (MI) or secondary to another process can be challenging. Our aim is to evaluate provider-level variation in the diagnosis of MI and the use of invasive coronary angiography (ICA) among patients with undifferentiated elevations in cardiac troponin.MethodsWe analyzed data from all patients with elevated troponin levels in a single Veterans Affairs (VA) Medical Center between 2006 and 2007. One of several cardiologists prospectively evaluated each patient’s presentation and course of care. We compared the frequency of MI diagnosis and ICA use between physicians using univariate odds ratios (OR).ResultsAmong 761 patients, 34.0 % were diagnosed with MI and 25.9 % underwent ICA. The unadjusted rates of MI (23.9 to 56.7 %, P = 0.02) and ICA (17.3 to 73.3 %, P < 0.001) differed between physicians. Comparing the patient cohorts for each physician, baseline characteristics were similar except for chest pain. In multivariate regression, factors associated with the use of cardiac ICA included an abnormal electrocardiograph (ECG) (OR = 1.89, P = 0.014), level of troponin (OR = 1.71, P = 0.004), chest pain (OR = 8.60, P < 0.001), and care by non-VA physicians (OR = 4.45, P = 0.006). One physician had a lower ICA use (OR = 0.56, P = 0.017). In multivariate regression of MI, no physician-level variation was observed.ConclusionAmong patients with elevated troponin, the likelihood of being diagnosed with MI and undergoing ICA is dependent on their clinical presentation. After adjustment, physician-level variation in care was observed for the use of ICA, but not for the diagnosis of MI.

Validation of the appropriate use criteria for coronary angiography: a cohort study.

The use of invasive coronary angiography in stable ischemic heart disease (IHD) varies widely. To validate the 2012 appropriate use criteria for diagnostic catheterization by examining the relationship between the appropriateness of cardiac catheterization in patients with suspected stable IHD and the proportion of patients with obstructive coronary artery disease (CAD) and subsequent revascularization. Population-based, observational, multicenter cohort study. The Cardiac Care Network, a registry of all patients having elective angiography at 18 hospitals in Ontario, Canada, between 1 October 2008 and 30 September 2011. Persons without prior coronary revascularization or myocardial infarction who had angiography for suspected stable CAD. Appropriateness scores were ascertained by using data collected at the time of the index angiography and were categorized as appropriate, inappropriate, or uncertain. Among the final cohort of 48336 patients, 58.2% of angiographic studies were classified as appropriate, 10.8% were classified as inappropriate, and 31.0% were classified as uncertain. Overall, 45.5% of patients had obstructive CAD. In patients with appropriate indications for angiography, 52.9% had obstructive CAD, with 40.0% undergoing revascularization. In those with inappropriate indications, 30.9% had obstructive CAD and 18.9% underwent revascularization; in those with uncertain indications, 36.7% had obstructive CAD and 25.9% had revascularization. Although more patients with appropriate indications had obstructive CAD and underwent revascularization (P< 0.001), a substantial proportion of those with inappropriate or uncertain indications had important coronary disease. Data were not available on whether symptoms were atypical. Despite the association between appropriateness category and obstructive CAD, this study raises concerns about the ability of the appropriate use criteria to guide clinical decision making. Canadian Institutes of Health Research.

CT coronary angiography in low- to intermediate-risk patients: Less radiation, less invasive angiography, and less revascularisation

Objectives. We investigated whether any change in the use of invasive coronary angiography and coronary revascularisation after CT coronary angiography in patients with a low to intermediate pre-test probability of coronary artery disease could be explained from alterations in patient characteristics. Design. A cohort study based on data samples from the Western Denmark Heart Registry. Follow-up ended on 11 March 2014. Results. A total of 3541 persons were examined during the period of January 2010–December 2013. The median radiation dose was reduced from 4.2 to 2.2 mSv (p < 0.001) due to improved technology. The immediate referral rate for subsequent myocardial perfusion scans was increased from 2.8% to 10.0% (p < 0.001), while the immediate referral rate for invasive coronary angiography decreased from 25.3% to 10.8% (p < 0.001). The revascularisation rate diminished from 10.4% to 6.3%. The multivariable adjusted hazard ratio (95% confidence interval) for invasive coronary angiography during follow-up after CT coronary angiography was 0.59 (0.47–0.74) and that for coronary revascularisation was 0.66 (0.45–0.97) in 2013 compared to that in 2010. Conclusions: The radiation dose diminished considerably. The reductions in the use of invasive coronary angiography and coronary revascularisation could not be explained by changes in patient characteristics but are driven by an increased use of perfusion scans in combination with increasing use of measurement of functional coronary flow reserve.

Sex comparison of diagnostic accuracy of 64-multidetector row coronary computed tomographic angiography: Results from the multicenter ACCURACY trial

The diagnosis of coronary artery disease (CAD) in women remains a challenge, given their lower prevalence of obstructive disease and the suboptimal performance of traditional noninvasive tests (exercise electrocardiography and stress myocardial perfusion imaging). Coronary computed tomographic angiography (CTA) is a validated method for detection and exclusion of obstructive coronary artery stenosis. We compared the diagnostic accuracy of coronary CTA between men and women without known CAD with the use of invasive coronary angiography (ICA) as the reference standard. We prospectively evaluated 230 subjects with chest pain at 16 sites who were clinically referred for ICA. ICAs were evaluated for coronary stenosis according to quantitative coronary angiography. Subjects (136 men and 94 women; mean ± age, 57 ± 10 years) underwent both CTA and ICA. For a patient-based model for stenosis >50%, sensitivity, specificity, positive and negative predictive values in men versus women were 96%, 78%, 69%, 100% and 90%, 88%, 47%, 99%, respectively. Subgroup analyses were performed for age and lifestyle risk factors. For stenosis > 50% in patients < 55 years, specificity in men versus women was 88% versus 95%, whereas for patients > 55 years, specificity in men versus women was 68% versus 82% (P < 0.05). Coronary CTA found comparable diagnostic accuracy for women in comparison with men for the detection of obstructive coronary stenosis at both thresholds of 50% and 70%.

Invasive Versus Noninvasive Evaluation of Coronary Artery Disease

We sought to compare the diagnostic information obtained from noninvasive characterization of coronary artery disease by using multidetector computed tomography (MDCT) and myocardial perfusion imaging (MPI) and to compare findings with the use of invasive coronary angiography and intravascular ultrasound (IVUS). Preliminary comparisons have suggested that abnormal myocardial perfusion studies correlate well with significant luminal stenosis on MDCT coronary angiography. However, atherosclerotic coronary lesions may be detectable with the use of MDCT even in the presence of normal myocardial perfusion We performed MDCT, MPI, and conventional coronary angiography in 70 patients. In addition, IVUS was performed in 53 patients. Quantitative information was obtained from quantitative coronary angiography (QCA) and IVUS assessment of plaque burden and minimal luminal area. Of 26 patients with an abnormal MPI study, 23 (88%) showed significant stenosis on MDCT. As compared with QCA, MDCT showed a sensitivity of 96% and specificity of 67% for the detection of stenoses > or =50% diameter narrowing in these patients. Mean diameter stenosis on QCA was 76% and mean minimal lumen area in IVUS was 3.3 mm(2). On the other hand, 27 (84%) of 44 patients with normal MPI had evidence of coronary atherosclerosis on MDCT (luminal stenosis > or =50%: n = 15, luminal stenosis <50%: n = 12, sensitivity of 100% and specificity of 83% as compared with QCA). Using IVUS, we found substantial plaque burden (mean 58.9 +/- 18.1% of cross-sectional area), but presence of a stenosis (minimal lumen area <4.0 mm(2)) in only 14 patients (mean minimal lumen area, 5.8 +/- 3.3 mm(2)). Only 7 patients with normal myocardial perfusion scans demonstrated absence of coronary atherosclerosis by MDCT. Considerable plaque burden can be observed with MDCT even in the absence of myocardial perfusion abnormalities. This finding does not constitute a false-positive MDCT result, but rather reflects the fact that MDCT can detect atherosclerotic lesions that are not flow-limiting.

Usefulness of Multislice Computed Tomographic Coronary Angiography to Identify Patients With Abnormal Myocardial Perfusion Stress in Whom Diagnostic Catheterization May Be Safely Avoided

Computed tomographic angiography (CTA) has been validated for noninvasive assessment of coronary anatomy. The aim was to establish whether CTA could guide the use of invasive coronary angiography (ICA) in symptomatic patients with intermediate risk after myocardial perfusion stress imaging (MPSI). From April 2005 to February 2006, patients referred for CTA to a cardiology practice were entered into a database. Inclusion required symptoms suggestive of coronary artery disease and intermediate-risk MPSI. Subjects with intermediate risk after MPSI underwent CTA, and if severe stenosis or moderate stenosis matching a perfusion defect was found, ICA was performed. If appropriate, patients were then sent for revascularization. Clinical follow-up was completed until December 2006. Main outcome measures were number of patients sent for ICA, immediate revascularization after ICA, and adverse outcomes (death, myocardial infarction, and late revascularization). Four hundred twenty-one patients were included. Adequate diagnostic-quality images were obtained in 99%. After MPSI-CTA assessment, 78 patients (18.5%) were sent for ICA and 343 (81.5%) were medically managed. Follow-up was 15+/-3 months. In the group referred for ICA, there were 50 cases of immediate revascularization, 1 non-ST-segment elevation myocardial infarction, 1 death, and 5 patients requiring repeat ICA, 3 of whom underwent late revascularization. In the medically managed group, 6 patients required late ICA, 1 of whom underwent revascularization. In conclusion, in symptomatic patients with suspected coronary artery disease and intermediate-risk MPSI results, CTA can identify up to 80% of patients at low risk of events in whom ICA may be safely avoided. Additional studies assessing new technologies combining MPSI-CTA are needed to refine imaging strategies in these patients.