Comparison of Anatomic and Clinical Outcomes in Patients Undergoing Alternative Initial Noninvasive Testing Strategies for the Diagnosis of Stable Coronary Artery Disease

Abstract

BackgroundThe optimal initial noninvasive diagnostic testing strategy for stable coronary artery disease (CAD) is unknown. Although American guidelines recommend an exercise stress test as the first‐line test, European guidelines suggest that stress imaging (myocardial perfusion imaging or stress echocardiography) or coronary computed tomography angiography may be preferable. Understanding the relationship between the initial strategy and downstream yield of obstructive CAD and major adverse cardiac events may provide insight as to the optimal strategy.Methods and ResultsWe conducted a population‐based retrospective cohort study of adults in Ontario, Canada, using health administrative and clinical data. The relationship between the initial testing strategy and obstructive CAD on invasive angiography was examined. Patients were then followed from their angiogram onward to determine whether they developed a composite end point of major adverse cardiac events. After adjusting for covariates, patients with initial myocardial perfusion imaging (odds ratio: 0.92; 95% confidence interval, 0.85, 1.00), coronary computed tomography angiography (odds ratio: 1.51; 95% confidence interval, 0.91, 2.49), or stress echo (odds ratio: 0.95; 95% confidence interval, 0.84, 1.08) did not a have significantly different yield of obstructive CAD compared with those with an initial exercise stress test. Furthermore, there was no significant difference in downstream major adverse cardiac events after invasive angiography among the 4 initial testing strategies after adjusting for clinically relevant covariates.ConclusionsOur study found no evidence to suggest significant differences in either yield of obstructive CAD or downstream major adverse cardiac events in patients undergoing an initial noninvasive testing strategy with stress or anatomical imaging compared with those undergoing an initial exercise stress test.

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

“…Although diagnostic ICA utilization was reduced using the coronary CTA/FFR CT strategy, among those with obstructive CAD, the proportion of ICA patients who underwent revascularization was 62% (34 of 55). Multiple other studies in various clinical settings, including Emergency Departments, the Veterans Affairs health system, and in various countries, have reported lower diagnostic yield and revascularization rates with a standard of care practice not incorporating FFR CT in the diagnostic pathway [47][48][49][50][51][52]. We observed a higher diagnostic yield of cardiac catheterization through improved patient selection combining anatomic with functional data in one platform using FFR CT.…”

2020 Clinical practice guidelines for Stable coronary artery disease

“…• Выбор первого неинвазивного визуализирующего метода рекомендуется проводить на основании ПТВ ИБС, особенностей пациента и собственно метода диагностики (переносимость нагрузки, вероятность получения изображения хорошего качества, наличие лучевой нагрузки, риски и противопоказания), технических возможностей медицинской организации и уровня квалификации специалистов [51][52][53].…”

“…• У пациентов с более низкой ПТВ ИБС (≤15%), низкой вероятностью реваскуляризации, ожидаемым изображением высокого качества, противопоказаниями к проведению нагрузочных тестов при наличии технической возможности и специалистов рекомендуется выбирать МСКТ-ангиографию КА в качестве первого специфического неинвазивного метода диагностики ИБС [51][52][53].…”

“…• У пациентов с более высокой ПТВ ИБС (>15%), высокой вероятностью выполнения реваскуляризации, необходимостью оценки жизнеспособности миокарда при наличии технической возможности и специалистов рекомендуется выбирать один из визуализирующих нагрузочных стресс-методов в качестве первого специфического неинвазивного метода диагностики ИБС (ЭхоКГ с физической нагрузкой, или ЭхоКГ с фармакологической нагрузкой, или сцинтиграфия миокарда с функциональными пробами, или ПЭТ, или ОФЭКТ, перфузионная с функциональными пробами) [51][52][53].…”

Initial Diagnostic Evaluation of Stable Coronary Artery Disease: The Need for a Patient‐Centered Strategy

“…In this issue of JAHA , Roifman and colleagues evaluated initial testing strategies for stable CAD with anatomical versus functional stressing modality in a nonselected general population 1. The cohort consisted of 15 467 patients who had undergone a noninvasive test, with the end point being obstructive coronary artery disease on invasive coronary angiography.…”