Comparison of Clinical Interpretation With Visual Assessment and Quantitative Coronary Angiography in Patients Undergoing Percutaneous Coronary Intervention in Contemporary Practice

Abstract

Background Studies conducted decades ago described substantial disagreement and errors in physicians’ angiographic interpretation of coronary stenosis severity. Despite the potential implications of such findings, no large-scale efforts to measure or improve clinical interpretation were subsequently made. Methods & Results We compared clinical interpretation of stenosis severity in coronary lesions with an independent assessment using quantitative coronary angiography (QCA) in 175 randomly selected patients undergoing elective percutaneous coronary intervention (PCI) at 7 U.S. hospitals in 2011. To assess agreement, we calculated mean difference in percent diameter stenosis between clinical interpretation and QCA and a Cohen’s weighted kappa statistic. Of 216 treated lesions, median percent diameter stenosis was 80.0% (Q1 and Q3, 80.0 and 90.0%) with 213 (98.6%) assessed as ≥70%. Mean difference in percent diameter stenosis between clinical interpretation and QCA was +8.2 ± 8.4%, reflecting an average higher percent diameter stenosis by clinical interpretation (P<0.001). A weighted kappa of 0.27 (95% CI, 0.18 to 0.36) was found between the 2 measurements. Of 213 lesions considered ≥70% by clinical interpretation, 56 (26.3%) were <70% by QCA though none was <50%. Differences between the 2 measurements were largest for intermediate lesions by QCA (50 to <70%) with variation existing across sites. Conclusions Physicians tended to assess coronary lesions treated with PCI as more severe than measurements by QCA. Almost all treated lesions were ≥70% by clinical interpretation, while approximately a quarter were <70% by QCA. These findings suggest opportunities to improve clinical interpretation of coronary angiography.

Visual and Quantitative Assessment of Coronary Stenoses at Angiography Versus Fractional Flow Reserve

“…Our results were similar and confirm in a larger population previous studies describing the difference observed between VE and QCA. [34][35][36] …”

Impact of Angiographic Residual Stenosis on Clinical Outcomes After New‐Generation Drug‐Eluting Stents Implantation: Insights From a Pooled Analysis of the RESET and NEXT Trials

“…Third, QCA is mainly used for research purposes, and is rarely performed in daily clinical practice, where the degree of stenosis is intuitively judged by the visual estimation. Visual assessment overestimates stenosis more than QCA measurement in highly stenotic lesions, while it underestimates stenosis in mildly stenotic ones 20, 21. It could be possible that the suboptimal results might be underestimated by visual estimation.…”

Comparison between fractional flow reserve and visual assessment for moderate coronary artery stenosis

“…Even when expert observers perform the visual assessment of the coronary arteries, inter-observer variabilities can be quite high [3]. Despite the fact that this is very well known, the most recent studies on this subject were made in the early 1990s, and to reveal the current status of this issue, Nallamothu et al [6] carried out a project called the "Assessing Angiography (A2) Project" as follows: In seven large hospitals in the United States, coronary angiographies of PCI-administered patients were selected randomly, the intervened stenosis was measured with quantitative methods (quantitative coronary angiography [QCA]) and compared to the visual assessment of the physician who carried out the process. In the study, the stenosis percentage of the physicians who read the lesions visually was found to be 84.2 ± 10.1 on average, and lesion severity was evaluated as ≥ 70% in 213 of the 216 evaluated patients.…”