After ISCHEMIA: Is coronary CTA the new gatekeeper?

The Radiologist as a Gatekeeper in Chest Pain

“…The remote evaluation, however, proved the use of the CT right; the use of a CT-driven protocol is beneficial in terms of outcome over standard assessment [ 62 ]. This result likely fits into the concept that better patient stratification leads to tailored therapies that lead to a better outcome [ 63 ].…”

“…The use of this approach would represent a clinical turning point, allowing a reduction in diagnosis times. To confirm the validity and effectiveness of this approach, however, further clinical studies are needed [ 63 ].…”

Stress-echocardiography or coronary computed tomography in suspected chronic coronary syndrome after the 2019 European Guidelines? A practical guide

“…[48][49][50][51][52] The distinctive role and apparent advantage of provocative/functional testing versus CCTA has historically been this 'gatekeeping role' to either proceed to invasive (revascularization) and medical treatment or standalone noninvasive medical management, based on the assessment of the presence and degree of reversible ischemia. 53,54 After the ISCHEMIA trial results, wherein even patients with moderate or severe reversible ischemia had apparently no clear advantage by being initially indicated for an invasive approach, there is now apparently no additional clinical advantage in the performance of functional testing before or in place of CCTA. In other words, why should we look for a parameter (the grade of reversible ischemia) that did not demonstrate any additional usefulness (in the first and only randomized study ever performed with hard endpoints) to answer the question of whether revascularization or medical therapeutic strategy is better?…”

“…The decision regarding the best following therapy can also be based on the CAD burden, plaque specific location in the coronary tree and, importantly, symptoms and their drug-sensitivity. [54][55][56] It remains common clinical practice, and current guidelines still support this concept, that more severe and/or diffused reversible ischemia at stress-echocardiography (or any other functional test) should be interpreted as reinforcing the indication for coronary artery…”

“…Regarding the second key point (guide therapy in case obstructive CAD is detected or suspected), the ISCHEMIA trial to some extent contradicts the prior (mostly retrospective studies) by strongly suggesting there is no or very limited value in being able to assess the presence or grade of reversible ischemia (using functional imaging tests) to establish whether or not a CAD patient should be (at least in the first instance) indicated for an invasive or medical strategy in chronic coronary syndromes (CCS) 48–52 . The distinctive role and apparent advantage of provocative/functional testing versus CCTA has historically been this ‘gatekeeping role’ to either proceed to invasive (revascularization) and medical treatment or standalone noninvasive medical management, based on the assessment of the presence and degree of reversible ischemia 53,54 . After the ISCHEMIA trial results, wherein even patients with moderate or severe reversible ischemia had apparently no clear advantage by being initially indicated for an invasive approach, there is now apparently no additional clinical advantage in the performance of functional testing before or in place of CCTA.…”