CT or Invasive Coronary Angiography in Stable Chest Pain Maurovich-Horvat, Pál; Bosserdt, Maria; Kofoed, Klaus F ...
New England journal of medicine/The New England journal of medicine,
04/2022, Letnik:
386, Številka:
17
Journal Article
Recenzirano
Odprti dostop
In the diagnosis of obstructive coronary artery disease (CAD), computed tomography (CT) is an accurate, noninvasive alternative to invasive coronary angiography (ICA). However, the comparative ...effectiveness of CT and ICA in the management of CAD to reduce the frequency of major adverse cardiovascular events is uncertain.
We conducted a pragmatic, randomized trial comparing CT with ICA as initial diagnostic imaging strategies for guiding the treatment of patients with stable chest pain who had an intermediate pretest probability of obstructive CAD and were referred for ICA at one of 26 European centers. The primary outcome was major adverse cardiovascular events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) over 3.5 years. Key secondary outcomes were procedure-related complications and angina pectoris.
Among 3561 patients (56.2% of whom were women), follow-up was complete for 3523 (98.9%). Major adverse cardiovascular events occurred in 38 of 1808 patients (2.1%) in the CT group and in 52 of 1753 (3.0%) in the ICA group (hazard ratio, 0.70; 95% confidence interval CI, 0.46 to 1.07; P = 0.10). Major procedure-related complications occurred in 9 patients (0.5%) in the CT group and in 33 (1.9%) in the ICA group (hazard ratio, 0.26; 95% CI, 0.13 to 0.55). Angina during the final 4 weeks of follow-up was reported in 8.8% of the patients in the CT group and in 7.5% of those in the ICA group (odds ratio, 1.17; 95% CI, 0.92 to 1.48).
Among patients referred for ICA because of stable chest pain and intermediate pretest probability of CAD, the risk of major adverse cardiovascular events was similar in the CT group and the ICA group. The frequency of major procedure-related complications was lower with an initial CT strategy. (Funded by the European Union Seventh Framework Program and others; DISCHARGE ClinicalTrials.gov number, NCT02400229.).
The quantification of coronary calcification has established itself as a valid risk marker to predict cardiovascular events. However, data derived from cardiac multi-detector row computed tomography ...could demonstrate that the exclusion of coronary calcification is not synonymous with the exclusion of coronary artery disease (CAD). The aims of this retrospective analysis were to determine the prevalence of significant CAD in a symptomatic cohort with indications for invasive angiography but without coronary calcification (Agatston score 0) as assessed by multislice computed tomography and to investigate whether there were any differences in terms of risk factors between patients with and without significant CAD.
Five hundred multislice computed tomographic scans (in 371 men and 129 women) were included in the analysis. Agatston scores were determined on native scans. All patients underwent coronary angiography to detect or rule out obstructive CAD. Patients with negative calcium scoring were selected and divided into two subgroups: those without obstructive CAD and those with obstructive CAD (luminal stenoses > 50%). These subgroups were characterized in terms of clinical characteristics (age and sex) and cardiovascular risk factors (diabetes mellitus, hypertension, hyperlipoproteinemia, familial predisposition, smoking, and overweight).
Sixty-one of 500 patients (12.2%) had negative calcium scores (Agatston score 0). Sixteen of these patients (26.3%, or 3.2% of the total population) had obstructive CAD according to invasive angiography. Patients with obstructive CAD were significantly older (mean age, 64 ± 9 vs 55 ± 10 years; P = .003) and were more frequently diabetic (25% vs 4%, P = .0389) than patients without obstructive CAD. There were no significant differences with regard to the other risk factors.
In this high-risk population, the absence of coronary calcification was not sufficient to rule out CAD. Among patients without coronary calcification, the presence of significant CAD was associated with increased age and the presence of diabetes mellitus.
The objective of this study was to evaluate the accuracy of electrocardiography (ECG)-gated 16-slice multidetector-row computed tomography (MDCT) in detection of stenosis of bypass grafts and native ...coronary arteries in patients who have undergone coronary artery bypass grafting (CABG). ECG-gated contrast-enhanced MDCT using 12 x 0.75-mm collimation was performed in 20 patients with recurrent angina 4.75 years after undergoing CABG. A total of 50 grafts, 16 arterial and 34 venous, were examined. All graft and coronary segments were evaluated for stenosis in comparison with conventional coronary angiography (CCA). Among the 80 arterial graft segments, 62 could be assessed (77.5%). Sensitivity, specificity, and positive and negative predictive values for stenosis were 96.2%, 97.2%, 96.2%, and 97.2%, respectively. In a total of 180 venous graft segments, 167 could be assessed. Sensitivity, specificity, and positive and negative predictive values for stenosis were 98.5%, 93.9%, 91.8%, and 98.9%, respectively. MDCT could assess 179 of 260 native coronary artery segments (68.8%). Sensitivity, specificity, and positive and negative predictive values for stenosis were 92.1%, 76.9%, 87.5%, and 84.7%, respectively. Sixteen-slice MDCT provides excellent image quality and diagnostic accuracy in detection of graft and coronary artery lesions in patients with suspected graft dysfunction.
The choice of imaging techniques in patients with suspected coronary artery disease (CAD) varies between countries, regions, and hospitals. This prospective, multicenter, comparative effectiveness ...study was designed to assess the relative accuracy of commonly used imaging techniques for identifying patients with significant CAD.
A total of 475 patients with stable chest pain and intermediate likelihood of CAD underwent coronary computed tomographic angiography and stress myocardial perfusion imaging by single photon emission computed tomography or positron emission tomography, and ventricular wall motion imaging by stress echocardiography or cardiac magnetic resonance. If ≥1 test was abnormal, patients underwent invasive coronary angiography. Significant CAD was defined by invasive coronary angiography as >50% stenosis of the left main stem, >70% stenosis in a major coronary vessel, or 30% to 70% stenosis with fractional flow reserve ≤0.8. Significant CAD was present in 29% of patients. In a patient-based analysis, coronary computed tomographic angiography had the highest diagnostic accuracy, the area under the receiver operating characteristics curve being 0.91 (95% confidence interval, 0.88-0.94), sensitivity being 91%, and specificity being 92%. Myocardial perfusion imaging had good diagnostic accuracy (area under the curve, 0.74; confidence interval, 0.69-0.78), sensitivity 74%, and specificity 73%. Wall motion imaging had similar accuracy (area under the curve, 0.70; confidence interval, 0.65-0.75) but lower sensitivity (49%, P<0.001) and higher specificity (92%, P<0.001). The diagnostic accuracy of myocardial perfusion imaging and wall motion imaging were lower than that of coronary computed tomographic angiography (P<0.001).
In a multicenter European population of patients with stable chest pain and low prevalence of CAD, coronary computed tomographic angiography is more accurate than noninvasive functional testing for detecting significant CAD defined invasively.
http://www.clinicaltrials.gov. Unique identifier: NCT00979199.
To prospectively evaluate the influence of the clinical pretest probability assessed by the Morise score onto image quality and diagnostic accuracy in coronary dual-source computed tomography ...angiography (DSCTA).
In 61 patients, DSCTA and invasive coronary angiography were performed. Subjective image quality and accuracy for stenosis detection (>50%) of DSCTA with invasive coronary angiography as gold standard were evaluated. The influence of pretest probability onto image quality and accuracy was assessed by logistic regression and chi-square testing. Correlations of image quality and accuracy with the Morise score were determined using linear regression.
Thirty-eight patients were categorized into the high, 21 into the intermediate, and 2 into the low probability group. Accuracies for the detection of significant stenoses were 0.94, 0.97, and 1.00, respectively. Logistic regressions and chi-square tests showed statistically significant correlations between Morise score and image quality (P < .0001 and P < .001) and accuracy (P = .0049 and P = .027). Linear regression revealed a cutoff Morise score for a good image quality of 16 and a cutoff for a barely diagnostic image quality beyond the upper Morise scale.
Pretest probability is a weak predictor of image quality and diagnostic accuracy in coronary DSCTA. A sufficient image quality for diagnostic images can be reached with all pretest probabilities. Therefore, coronary DSCTA might be suitable also for patients with a high pretest probability.
To assess the comparative effectiveness of computed tomography and invasive coronary angiography in women and men with stable chest pain suspected to be caused by coronary artery disease.
...Prospective, multicentre, randomised pragmatic trial.
Hospitals at 26 sites in 16 European countries.
2002 (56.2%) women and 1559 (43.8%) men (total of 3561 patients) with suspected coronary artery disease referred for invasive coronary angiography on the basis of stable chest pain and a pre-test probability of obstructive coronary artery disease of 10-60%.
Both women and men were randomised 1:1 (with stratification by gender and centre) to a strategy of either computed tomography or invasive coronary angiography as the initial diagnostic test (1019 and 983 women, and 789 and 770 men, respectively), and an intention-to-treat analysis was performed. Randomised allocation could not be blinded, but outcomes were assessed by investigators blinded to randomisation group.
The primary endpoint was major adverse cardiovascular events (MACE; cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke). Key secondary endpoints were an expanded MACE composite (cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, transient ischaemic attack, or major procedure related complication) and major procedure related complications.
Follow-up at a median of 3.5 years was available in 98.9% (1979/2002) of women and in 99.0% (1544/1559) of men. No statistically significant gender interaction was found for MACE (P=0.29), the expanded MACE composite (P=0.45), or major procedure related complications (P=0.11). In both genders, the rate of MACE did not differ between the computed tomography and invasive coronary angiography groups. In men, the expanded MACE composite endpoint occurred less frequently in the computed tomography group than in the invasive coronary angiography group (22 (2.8%)
41 (5.3%); hazard ratio 0.52, 95% confidence interval 0.31 to 0.87). In women, the risk of having a major procedure related complication was lower in the computed tomography group than in the invasive coronary angiography group (3 (0.3%)
21 (2.1%); hazard ratio 0.14, 0.04 to 0.46).
This study found no evidence for a difference between women and men in the benefit of using computed tomography rather than invasive coronary angiography as the initial diagnostic test for the management of stable chest pain in patients with an intermediate pre-test probability of coronary artery disease. An initial computed tomography scan was associated with fewer major procedure related complications in women and a lower frequency of the expanded MACE composite in men.
NCT02400229ClinicalTrials.gov NCT02400229.
This study assesses the global left ventricular function and volumes using dual-source computed tomography (DSCT) with improved temporal resolution (83 ms) by use of a semi-automatic software tool in ...comparison to invasive angiography (IVA). One hundred patients scheduled for invasive coronary angiography because of suspected or known coronary artery disease (80 men; 20 women, mean age 62 ± 10 years) were additionally examined by DSCT. Global left ventricular function (LVF), left ventricular end-diastolic volume (LVEDV), end-systolic volume (LVESV), and stroke volume (SV) were calculated by the use of semi-automatic post-processing software and results compared with those of IVA. Bland-Altman analysis revealed a good concordance between DSCT and IVA in terms of LVF: Pearson’s
r
0.78, confidence interval CI 0.68–0.86,
P
< 0.0001, bias 7.1% ± 9.1%. The same was true for LVESV (Pearson’s
r
0.78, CI 0.67–0.85,
P
< 0.0001, bias 15.0 ± 21.0 ml), whereas the agreement for LVEDV and SV was only moderate (LVEDV: Pearson’s
r
0.59, CI 0.43–0.72,
P
< 0.0001, bias 13.0 ± 18.1 ml; SV: Pearson’s
r
0.47, CI 0.28–0.62,
P
< 0.0001, bias −1.4 ± 28.4 ml). Semi-automatic evaluation of left ventricular parameters with DSCT revealed good correlation for LVF and LVESV, whereas LVEDV and SV showed only a moderate correlation. Moreover, LVF is systematically underestimated by DSCT.
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