Cardiac computed tomographic angiography after abnormal ischemia test as a gatekeeper to invasive coronary angiography

Abstract

ObjectivesThis study aimed to determine the impact of systematic coronary computed tomographic angiography (CCTA) use following an abnormal non-invasive ischemia test (NIST) on patient selection strategy for invasive coronary angiography (ICA). BackgroundIn patients with suspected stable coronary artery disease (CAD), NIST use frequently results in suboptimal diagnostic and revascularization yields of ICA. MethodsThis randomized clinical trial, conducted at a single academic tertiary center, selected 220 symptomatic patients with mild-to-moderately abnormal NIST results who were referred for ICA. Patients received either the originally intended ICA (n = 105) or CCTA (n = 115). The primary endpoint was the diagnostic yield of ICA in each group. Revascularization yield and major adverse cardiovascular events at 12 months were also assessed. ResultsThe patients were 69 ± 9 years old, 60% were men, and 31% had typical angina. Mean pre-test probability of obstructive CAD was 34%. Overall prevalence of obstructive CAD was 37.7% on the index angiographic procedure. In the CCTA group, ICA was cancelled by referring physicians in 83 patients (72.2%) after receiving CCTA results. For those undergoing ICA, diagnostic (84.4% vs 41.7%, p < 0.001) and revascularization (71.9% vs 38.8%, p = 0.001) yields were signi cantly higher for CCTA-guided ICA than for standard NIST-guided ICA. Mean cumulative radiation exposure was signi cantly lower in the CCTAguided ICA arm than in the NIST-guided ICA arm (12 ± 9 vs 16 ± 10 mSv, respectively, p = 0.024). There were no signi cant differences in the primary safety endpoint rates between the strategies (p = 0.439). ConclusionsIn patients with suspected CAD and mild-to-moderately abnormal ischemia tests, a diagnostic strategy including CCTA as a gatekeeper is safe and effective and signi cantly improves diagnostic and revascularization yields of ICA.

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

“…However, asymptomatic patients accounted for only 11% of the study population in the trial. 14 Reis et al 16 included only patients with clinical suspicion of CAD and an abnormal functional study by exercise treadmill stress test and single-photon emission computed tomography. The Table summarizes the characteristics of the population included in this meta-analysis…”

“…For stroke, the results were no longer statistically significant between groups when excluding either CAD-MAN trial (Coronary Artery Disease Management), DISCHARGE trial (Diagnostic Imaging Strategies for Patients with Stable Chest Pain and Intermediate Risk of Coronary Artery Disease), or the study by Reis et al (Figure S5). 12,15,16 However, it is important to highlight the complete absence of heterogeneity in the pooled analysis with all studies (I 2 =0%), which indicates that the results of each individual study are consistent with the results of the others. Therefore, the most likely explanation for the findings in the incidence of stroke with the leave-one-out calculations is the limited power in the sensitivity analyses after removing each study, rather than a true misleading effect of 1 individual study.…”

“…Of these, 5 RCTs were included, with a nonoverlapping population of 5727 patients, of whom 2928 (51.1%) underwent CCTA and 2799 (48.9%) underwent direct ICA. [12][13][14][15][16] All 5 included studies were identified in each of the 3 databases used for the systematic review. The list of studies reviewed in full and excluded is available in the Supplemental Material.…”

“…The risk of bias assessment with the Cochrane RoB2 tool is displayed in Table S1. Reis et al 16 was labeled as having some concerns due to the lack of definition of each outcome and a prospective protocol detailing measurement and reporting of events. The remaining RCTs were labeled as of low risk of bias.…”

“…[9][10][11] The comparative effectiveness of CCTA versus ICA in patients referred for ICA for suspected stable angina, with or without previous functional testing, has been the subject of recent randomized controlled trials (RCTs). [12][13][14][15][16] Overall, these trials have shown that using CCTA as a gatekeeper to ICA is a safe strategy in terms of composite cardiovascular end points. However, the comparison between these 2 strategies with regard to individual safety and efficacy end points is not clear due to limited power in clinical trials for individual end points.…”