Clinical effectiveness of coronary computed tomographic angiography in the triage of patients to cardiac catheterization and revascularization after inconclusive stress testing: Results of a 2-year prospective trial

Aiden Abidov, Michael J. Gallagher, Kavitha M. Chinnaiyan, Laxmi S. Mehta, James H. Wegner, Gilbert L. Raff

Research output: Contribution to journalArticle

44 Citations (Scopus)

Abstract

Background: Management of patients with suspected coronary artery disease (CAD) and inconclusive stress imaging test findings may result in invasive coronary angiography (ICA). Coronary computed tomographic angiography (CCTA) may be useful in defining the risk of CAD and adverse outcomes in this patient population, as well as in reducing the need for ICA. Methods: We prospectively enrolled 199 sequential patients referred by cardiologists for CCTA after either inconclusive or nondiagnostic stress imaging tests. Before CCTA, physicians identified a "planned catheterization" group of patients who would undergo invasive angiography if CCTA were not available. After CCTA testing, patients were followed for -2 years. We established the added diagnostic value of the CCTA and its prognostic power in prediction of intermediate-term follow-up events in this patient population as compared to available historical and clinical predictors of CAD, stress ECG, and stress imaging test results using a multivariable Cox proportional hazards survival analysis. Results: Both observed data and results of the multivariable model for the prediction of obstructive CAD (>50% stenosis), or major cardiac events (death MI or revascularization), demonstrated that clinical, stress ECG, and imaging results were weakly predictive, whereas CCTA was found to be a strong independent and incremental predictor of the absence of either significant CAD or MACE in this population. None of the 93 patients with normal CCTA scans had MACE events, whereas 18 patients with evidence of CAD on the CCTA results underwent revascularization. Overall, physicians planned ICA in 125 patients (63.0%); after CCTA, ICA was performed in only 32 (16.0%) cases over 2 years. In this population with no other highly effective noninvasive clinical tools for diagnostic and prognostic estimation, the overall negative predictive value of CCTA for either CAD > 50% or MACE for 2 years was 99%. Conclusion: Observations from this prospective study demonstrate the significant added diagnostic value and prognostic potential of CCTA in patients with suspected CAD and either inconclusive or nondiagnostic stress test results in real-world settings. Normal CCTA results are associated with excellent intermediate-term prognosis in this clinical subset, and invasive angiography can be safely avoided in the majority of these patients when the results of CCTA are available.

Original languageEnglish (US)
Pages (from-to)701-713
Number of pages13
JournalJournal of Nuclear Cardiology
Volume16
Issue number5
DOIs
StatePublished - 2009

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Triage
Cardiac Catheterization
Angiography
Coronary Artery Disease
Coronary Angiography
Exercise Test
Population
Electrocardiography
Physicians
Survival Analysis
Catheterization

Keywords

  • Cardiacstress testing
  • Coronary artery disease
  • Coronary CT angiography
  • Diagnosis
  • Prognosis

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Radiology Nuclear Medicine and imaging

Cite this

Clinical effectiveness of coronary computed tomographic angiography in the triage of patients to cardiac catheterization and revascularization after inconclusive stress testing : Results of a 2-year prospective trial. / Abidov, Aiden; Gallagher, Michael J.; Chinnaiyan, Kavitha M.; Mehta, Laxmi S.; Wegner, James H.; Raff, Gilbert L.

In: Journal of Nuclear Cardiology, Vol. 16, No. 5, 2009, p. 701-713.

Research output: Contribution to journalArticle

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abstract = "Background: Management of patients with suspected coronary artery disease (CAD) and inconclusive stress imaging test findings may result in invasive coronary angiography (ICA). Coronary computed tomographic angiography (CCTA) may be useful in defining the risk of CAD and adverse outcomes in this patient population, as well as in reducing the need for ICA. Methods: We prospectively enrolled 199 sequential patients referred by cardiologists for CCTA after either inconclusive or nondiagnostic stress imaging tests. Before CCTA, physicians identified a {"}planned catheterization{"} group of patients who would undergo invasive angiography if CCTA were not available. After CCTA testing, patients were followed for -2 years. We established the added diagnostic value of the CCTA and its prognostic power in prediction of intermediate-term follow-up events in this patient population as compared to available historical and clinical predictors of CAD, stress ECG, and stress imaging test results using a multivariable Cox proportional hazards survival analysis. Results: Both observed data and results of the multivariable model for the prediction of obstructive CAD (>50{\%} stenosis), or major cardiac events (death MI or revascularization), demonstrated that clinical, stress ECG, and imaging results were weakly predictive, whereas CCTA was found to be a strong independent and incremental predictor of the absence of either significant CAD or MACE in this population. None of the 93 patients with normal CCTA scans had MACE events, whereas 18 patients with evidence of CAD on the CCTA results underwent revascularization. Overall, physicians planned ICA in 125 patients (63.0{\%}); after CCTA, ICA was performed in only 32 (16.0{\%}) cases over 2 years. In this population with no other highly effective noninvasive clinical tools for diagnostic and prognostic estimation, the overall negative predictive value of CCTA for either CAD > 50{\%} or MACE for 2 years was 99{\%}. Conclusion: Observations from this prospective study demonstrate the significant added diagnostic value and prognostic potential of CCTA in patients with suspected CAD and either inconclusive or nondiagnostic stress test results in real-world settings. Normal CCTA results are associated with excellent intermediate-term prognosis in this clinical subset, and invasive angiography can be safely avoided in the majority of these patients when the results of CCTA are available.",
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T1 - Clinical effectiveness of coronary computed tomographic angiography in the triage of patients to cardiac catheterization and revascularization after inconclusive stress testing

T2 - Results of a 2-year prospective trial

AU - Abidov, Aiden

AU - Gallagher, Michael J.

AU - Chinnaiyan, Kavitha M.

AU - Mehta, Laxmi S.

AU - Wegner, James H.

AU - Raff, Gilbert L.

PY - 2009

Y1 - 2009

N2 - Background: Management of patients with suspected coronary artery disease (CAD) and inconclusive stress imaging test findings may result in invasive coronary angiography (ICA). Coronary computed tomographic angiography (CCTA) may be useful in defining the risk of CAD and adverse outcomes in this patient population, as well as in reducing the need for ICA. Methods: We prospectively enrolled 199 sequential patients referred by cardiologists for CCTA after either inconclusive or nondiagnostic stress imaging tests. Before CCTA, physicians identified a "planned catheterization" group of patients who would undergo invasive angiography if CCTA were not available. After CCTA testing, patients were followed for -2 years. We established the added diagnostic value of the CCTA and its prognostic power in prediction of intermediate-term follow-up events in this patient population as compared to available historical and clinical predictors of CAD, stress ECG, and stress imaging test results using a multivariable Cox proportional hazards survival analysis. Results: Both observed data and results of the multivariable model for the prediction of obstructive CAD (>50% stenosis), or major cardiac events (death MI or revascularization), demonstrated that clinical, stress ECG, and imaging results were weakly predictive, whereas CCTA was found to be a strong independent and incremental predictor of the absence of either significant CAD or MACE in this population. None of the 93 patients with normal CCTA scans had MACE events, whereas 18 patients with evidence of CAD on the CCTA results underwent revascularization. Overall, physicians planned ICA in 125 patients (63.0%); after CCTA, ICA was performed in only 32 (16.0%) cases over 2 years. In this population with no other highly effective noninvasive clinical tools for diagnostic and prognostic estimation, the overall negative predictive value of CCTA for either CAD > 50% or MACE for 2 years was 99%. Conclusion: Observations from this prospective study demonstrate the significant added diagnostic value and prognostic potential of CCTA in patients with suspected CAD and either inconclusive or nondiagnostic stress test results in real-world settings. Normal CCTA results are associated with excellent intermediate-term prognosis in this clinical subset, and invasive angiography can be safely avoided in the majority of these patients when the results of CCTA are available.

AB - Background: Management of patients with suspected coronary artery disease (CAD) and inconclusive stress imaging test findings may result in invasive coronary angiography (ICA). Coronary computed tomographic angiography (CCTA) may be useful in defining the risk of CAD and adverse outcomes in this patient population, as well as in reducing the need for ICA. Methods: We prospectively enrolled 199 sequential patients referred by cardiologists for CCTA after either inconclusive or nondiagnostic stress imaging tests. Before CCTA, physicians identified a "planned catheterization" group of patients who would undergo invasive angiography if CCTA were not available. After CCTA testing, patients were followed for -2 years. We established the added diagnostic value of the CCTA and its prognostic power in prediction of intermediate-term follow-up events in this patient population as compared to available historical and clinical predictors of CAD, stress ECG, and stress imaging test results using a multivariable Cox proportional hazards survival analysis. Results: Both observed data and results of the multivariable model for the prediction of obstructive CAD (>50% stenosis), or major cardiac events (death MI or revascularization), demonstrated that clinical, stress ECG, and imaging results were weakly predictive, whereas CCTA was found to be a strong independent and incremental predictor of the absence of either significant CAD or MACE in this population. None of the 93 patients with normal CCTA scans had MACE events, whereas 18 patients with evidence of CAD on the CCTA results underwent revascularization. Overall, physicians planned ICA in 125 patients (63.0%); after CCTA, ICA was performed in only 32 (16.0%) cases over 2 years. In this population with no other highly effective noninvasive clinical tools for diagnostic and prognostic estimation, the overall negative predictive value of CCTA for either CAD > 50% or MACE for 2 years was 99%. Conclusion: Observations from this prospective study demonstrate the significant added diagnostic value and prognostic potential of CCTA in patients with suspected CAD and either inconclusive or nondiagnostic stress test results in real-world settings. Normal CCTA results are associated with excellent intermediate-term prognosis in this clinical subset, and invasive angiography can be safely avoided in the majority of these patients when the results of CCTA are available.

KW - Cardiacstress testing

KW - Coronary artery disease

KW - Coronary CT angiography

KW - Diagnosis

KW - Prognosis

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