CT ‘effective gatekeeper’ for coronary angiography
medwireNews: Cardiac computed tomography (CT) can be used as the initial diagnostic procedure in patients clinically indicated for invasive coronary angiography as a result of suspected coronary artery disease (CAD) with an atypical presentation, suggests German research.
The primary endpoint of major procedural complications – defined as death, stroke, myocardial infarction, or other events extending the hospital stay by a day or more – within 48 hours of the last procedure did not differ significantly between the CT and coronary angiography groups.
Indeed, just one major complication was recorded in the short term – one instance of myocardial infarction in a patient in the CT arm after percutaneous coronary intervention – which was “lower than assumed” and resulted in “an underpowered study for the predefined primary outcome, making the study inconclusive in this regard,” the investigators admit.
Nevertheless, minor complications within 48 hours of the last procedure occurred significantly less often among patients who underwent CT versus coronary angiography, at 3.6% and 10.5%, respectively.
And only 14% of the participants in the CT group subsequently needed coronary angiography, “indicating the potential to reduce overuse of invasive procedures,” say Marc Dewey, from Charité-Universitätsmedizin Berlin, and collaborators.
Furthermore, coronary angiography in patients who had initially undergone cardiac CT had a significant fivefold greater diagnostic yield, defined as the proportion of coronary angiographies showing obstructive CAD, at 75% of 24 procedures versus 15% of 162 direct coronary angiographies.
Writing in The BMJ, the study authors observe: “CT may thus be able to act as an effective gatekeeper to the catheterisation laboratory and increase the reported low diagnostic yield of coronary angiography.”
Moreover, patients who underwent CT had a significantly shorter length of stay in the hospital than their counterparts in the coronary angiography arm, at a median of 30.0 and 52.9 hours, respectively, which “might help reduce costs when CT is used in properly selected patients with atypical presentation,” they comment.
Both diagnostic procedures were associated with a comparable exposure to radiation, and cardiac CT did not increase the long-term incidence of major adverse cardiovascular events, as assessed over a median follow-up of 3.3 years.
The single-institution trial comprised 329 patients with suspected CAD and a clinical indication for coronary angiography due to atypical angina or chest pain; 167 were randomly assigned to undergo cardiac CT and 162 to undergo coronary angiography.
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