Frontline diagnostic evaluation of patients suspected of angina by coronary computed tomography reduces downstream resource utilization when compared to conventional ischemia testing

Abstract

It has been proposed that the increasing use of coronary computed tomographic angiography (CTA) may introduce additional unnecessary diagnostic procedures. However, no previous study has assessed the impact on downstream test utilization of conventional diagnostic testing relative to CTA in patients suspected of angina. The purpose of this study was to investigate the consequences of frontline exercise-stress testing (Ex-test) versus CTA on downstream test utilization in clinical practice. In two collaborating departments using either Ex-test (n = 247) or CTA (n = 251) as the frontline diagnostic test in patients suspected of angina, comparable cohorts of consecutive patients were retrospectively identified (Jan. 2007-Feb. 2008). Downstream test utilization (invasive coronary angiography, ICA; myocardial perfusion scintigraphy, and CTA) during 12 months after the index diagnostic test was recorded. Mean age was 56 years (51% men), and 96% of the total study cohort were at low-intermediate pretest risk of significant coronary disease. Overall, downstream test utilization was more frequent in the Ex-test group than in the CTA group, 32% versus 21% (P = 0.003). Subsequent myocardial scintigraphy was more frequent used (9% versus 4%, P = 0.03), whereas ICA tended to be more frequent applied in the Ex-test versus CTA group (23% vs. 18%, P = 0.15). A frontline diagnostic use in symptomatic patients of Ex-test in comparison to CTA leads to more downstream diagnostic test utilization. Future prospective trials are needed in order to define the most cost-effective diagnostic use of CTA relative to conventional ischemia testing.

Cardiac CT vs. Stress Testing in Patients with Suspected Coronary Artery Disease: Review and Expert Recommendations

“…The latter typically requires longer follow up which is rarely given in contemporary studies. In an interesting analysis, Neilson et al investigated the impact of frontline exercise stress testing vs. CCTA on downstream test utilization in low to intermediate risk symptomatic patients [52]. The authors found lower rates of downstream testing in the CCTA group compared with stress testing with fewer uses of cardiac catheterization.…”

Impact of Coronary Computed Tomographic Angiography Results on Patient and Physician Behavior in a Low-Risk Population

“…We stress that our results do not apply to those with angina symptoms, when CCTA may have benefit in resource utilization. 31,32 They also do not apply to CAC testing in asymptomatic patients, where downstream resource utilization is minimal in those with scores lower than 400 Agatston units. 33…”

Nationwide Trends of Gatekeeper to Invasive Coronary Angiography in Suspected Coronary Artery Disease

“…19) 20) Our results are in concordance with previous results revealing the highest revascularization rate after ICA in patients who underwent CCTA as a gatekeeper. 21) 22) Our data showed that CCTA resulted in fewer unnecessary ICAs and a higher yield of obstructive CAD at ICA leading to revascularization. Recently, the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial has demonstrated that CAD severity assessed on CCTA, but not ischemia severity assessed on stress testing, predicted 4-year mortality and MI risk.…”