Selective Referral Using CCTA Versus Direct Referral for Individuals Referred to Invasive Coronary Angiography for Suspected CAD

Chang, Hyuk Jae; Lin, Fay Y.; Gebow, Dan; An, Hae Young; Andreini, Daniele; Bathina, Ravi; Baggiano, Andrea; Beltrama, Virginia; Cerci, Rodrigo; Choi, Eui Young; Choi, Jung Hyun; Choi, So Yeon; Chung, Namsik; Cole, Jason; Doh, Joon Hyung; Ha, Sang Jin; Her, Ae Young; Kępka, Cezary; Kim, Jang Young; Kim, Jin Won; Kim, Sang Wook; Kim, Woong; Pontone, Gianluca; Valeti, Uma; Villines, Todd C.; Lu, Yao; Kumar, Amit; Cho, Iksung; Danad, Ibrahim; Han, Donghee; Heo, Ran; Lee, Sang Eun; Lee, Ji Hyun; Park, Hyung Bok; Sung, Ji Min; Leflang, David; Zullo, Joseph; Shaw, Leslee J.; Min, James K.

doi:10.1016/j.jcmg.2018.09.018

Cited by 108 publications

(72 citation statements)

References 29 publications

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“… 8 A similar safety profile with non-inferiority of CTA versus invasive coronary angiography in terms of major cardiovascular events at one year was found in the CONSERVE trial. 43 However, coronary CTA still has to be analysed in a multicentre study of patients with a clinical indication for invasive coronary angiography, and the randomised DISCHARGE trial will provide more data in this regard. 44 …”

Section: Discussionmentioning

confidence: 99%

Diagnosis of obstructive coronary artery disease using computed tomography angiography in patients with stable chest pain depending on clinical probability and in clinically important subgroups: meta-analysis of individual patient data

Haase

Schlattmann

Guéret

et al. 2019

BMJ

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113

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Objective To determine whether coronary computed tomography angiography (CTA) should be performed in patients with any clinical probability of coronary artery disease (CAD), and whether the diagnostic performance differs between subgroups of patients. Design Prospectively designed meta-analysis of individual patient data from prospective diagnostic accuracy studies. Data sources Medline, Embase, and Web of Science for published studies. Unpublished studies were identified via direct contact with participating investigators. Eligibility criteria for selecting studies Prospective diagnostic accuracy studies that compared coronary CTA with coronary angiography as the reference standard, using at least a 50% diameter reduction as a cutoff value for obstructive CAD. All patients needed to have a clinical indication for coronary angiography due to suspected CAD, and both tests had to be performed in all patients. Results had to be provided using 2×2 or 3×2 cross tabulations for the comparison of CTA with coronary angiography. Primary outcomes were the positive and negative predictive values of CTA as a function of clinical pretest probability of obstructive CAD, analysed by a generalised linear mixed model; calculations were performed including and excluding non-diagnostic CTA results. The no-treat/treat threshold model was used to determine the range of appropriate pretest probabilities for CTA. The threshold model was based on obtained post-test probabilities of less than 15% in case of negative CTA and above 50% in case of positive CTA. Sex, angina pectoris type, age, and number of computed tomography detector rows were used as clinical variables to analyse the diagnostic performance in relevant subgroups. Results Individual patient data from 5332 patients from 65 prospective diagnostic accuracy studies were retrieved. For a pretest probability range of 7-67%, the treat threshold of more than 50% and the no-treat threshold of less than 15% post-test probability were obtained using CTA. At a pretest probability of 7%, the positive predictive value of CTA was 50.9% (95% confidence interval 43.3% to 57.7%) and the negative predictive value of CTA was 97.8% (96.4% to 98.7%); corresponding values at a pretest probability of 67% were 82.7% (78.3% to 86.2%) and 85.0% (80.2% to 88.9%), respectively. The overall sensitivity of CTA was 95.2% (92.6% to 96.9%) and the specificity was 79.2% (74.9% to 82.9%). CTA using more than 64 detector rows was associated with a higher empirical sensitivity than CTA using up to 64 rows (93.4% v 86.5%, P=0.002) and specificity (84.4% v 72.6%, P<0.001). The area under the receiver-operating-characteristic curve for CTA was 0.897 (0.889 to 0.906), and the diagnostic performance of CTA was slightly lower in women than in with men (area under the curve 0.874 (0.858 to 0.890) v 0.907 (0.897 to 0.916), P<0.001). The diagnostic performance of CTA was slightly lower in patients older than 75 (0.864 (0.834 to 0.894), P=0.018 v all other age groups) and was not significantly influenced by angina pectoris type (typical angina 0.895 (0.873 to 0.917), atypical angina 0.898 (0.884 to 0.913), non-anginal chest pain 0.884 (0.870 to 0.899), other chest discomfort 0.915 (0.897 to 0.934)). Conclusions In a no-treat/treat threshold model, the diagnosis of obstructive CAD using coronary CTA in patients with stable chest pain was most accurate when the clinical pretest probability was between 7% and 67%. Performance of CTA was not influenced by the angina pectoris type and was slightly higher in men and lower in older patients. Systematic review registration PROSPERO CRD42012002780.

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Section: Discussionmentioning

confidence: 99%

Diagnosis of obstructive coronary artery disease using computed tomography angiography in patients with stable chest pain depending on clinical probability and in clinically important subgroups: meta-analysis of individual patient data

Haase

Schlattmann

Guéret

et al. 2019

BMJ

Self Cite

113

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“…No studies as yet have been conducted to evaluate the advantages of both of these approaches. A randomized CONSERVE study, which included patients with suspected CAD regardless of age, showed that coronary CTA was associated with reduced frequency of CAG that did not reveal CAD and reduced cost of the diagnostic procedures [ 64 ].…”

Section: Coronary Computed Tomography Angiography For Diagnosis Ofmentioning

confidence: 99%

Noninvasive Testing for Diagnosis of Stable Coronary Artery Disease in the Elderly

Kozlov

Chernova

Gerasimova

et al. 2020

IJMS

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Efficient diagnostic approaches to detect coronary artery disease (CAD) in elderly patients are necessary to ensure optimal and timely treatment. The population of suspected CAD patients older than 70 years is especially vulnerable and constantly growing. Finding the optimal diagnostic approach is challenging due to certain features of this population, such as high prevalence of comorbidities, existing contraindications to exercise tests or cognitive decline, which hinders correct assessment of the patient’s situation. Moreover, some symptoms of CAD can have variable significance in the elderly compared to younger adult groups. In this review, we present current recommendations of the United States (US) and European cardiologists’ associations and discuss their applicability for diagnostics in the elderly population. Exercise electrocardiogram (ECG) and exercise stress echocardiography (SE) tests are not feasible for a substantial proportion of elderly patients. Coronary computed tomography angiography (CTA) appears to be an attractive alternative for such patients, but is not universally applicable; for instance, it is problematic in patients with significant calcification of the vessels. Moreover, more studies are needed to compare the results delivered by CTA to those of other diagnostic methods. Future efforts should be focused on comparative studies to better understand the limits and advantages of different diagnostic methods and their combinations. It is possible that some of the currently used diagnostic criteria could be improved to better accommodate the needs of the elderly population.

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“…The recent CONSERVE (Coronary Computed Tomographic Angiography for Selective Cardiac Catheterization) trial randomized 1,611 patients to either direct ICA or CCTA, with ICA performed at the discretion of the local physician informed by the CCTA findings [21]. Eligible patients had suspected but no known CAD and a class II indication for non-emergent ICA based upon the ACC/AHA guidelines [22].…”

Section: Coronary Cta To Select Patients For Ica and Revascularizationmentioning

confidence: 99%

Coronary Computed Tomography Angiography as a Gatekeeper to Coronary Revascularization: Emphasizing Atherosclerosis Findings Beyond Stenosis

Hoogen

Rosendael

Lin

et al. 2019

Curr Cardiovasc Imaging Rep

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Purpose of Review Coronary computed tomography angiography (CCTA) is the optimal non-invasive test to rule out coronary artery disease (CAD). Decisions to perform coronary revascularization have traditionally been based upon ischemia testing. This review summarizes the latest observations and trials evaluating the suitability of CCTA to select patients for invasive coronary angiography (ICA) and subsequent revascularization. Recent Findings Recent data shows that beyond stenosis, whole-heart quantification and characterization of coronary atherosclerotic plaque improves the estimation of myocardial ischemia. This comprehensive evaluation of the coronary artery tree has greater diagnostic accuracy for invasive fractional flow reserve (FFR) than conventional stress tests. Further, clinical trials have demonstrated that the performance of CCTA in patients with a clinical indication for ICA results in more effective patient care and significantly lower costs. Summary Besides the excellent ability to rule out CAD, recent data shows that quantification and characterization of the coronary artery tree results in high accuracy for ischemia and that CCTA-guided care to select patients for ICA and revascularization is effective. Trials evaluating revascularization based on CCTA findings may be needed.

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Selective Referral Using CCTA Versus Direct Referral for Individuals Referred to Invasive Coronary Angiography for Suspected CAD

Cited by 108 publications

References 29 publications

Diagnosis of obstructive coronary artery disease using computed tomography angiography in patients with stable chest pain depending on clinical probability and in clinically important subgroups: meta-analysis of individual patient data

Diagnosis of obstructive coronary artery disease using computed tomography angiography in patients with stable chest pain depending on clinical probability and in clinically important subgroups: meta-analysis of individual patient data

Noninvasive Testing for Diagnosis of Stable Coronary Artery Disease in the Elderly

Coronary Computed Tomography Angiography as a Gatekeeper to Coronary Revascularization: Emphasizing Atherosclerosis Findings Beyond Stenosis

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