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Published on: August 28, 2018
A long-term prognostic value of CT angiography and exercise ECG in patients with suspected CAD
Gianluca Pontone1, Daniele Andreini, Antonio L Bartorelli
1Centro Cardiologico Monzino, IRCCS, Milan, Italy. gianluca.pontone@ccfm.it
Insights
Computed tomography coronary angiography (CTA) offers superior prognostic value over exercise electrocardiography (ex-ECG) for identifying cardiac events in patients with suspected coronary artery disease (CAD). CTA is particularly effective in patients with low to intermediate pre-test likelihood of CAD.
Area of Science:
- Cardiology
- Medical Imaging
- Diagnostic Accuracy
Background:
- Coronary artery disease (CAD) is a leading cause of mortality and morbidity.
- Accurate risk stratification is crucial for managing CAD patients.
- Exercise electrocardiography (ex-ECG) is common but has limited accuracy; computed tomography coronary angiography (CTA) is an emerging alternative.
Purpose of the Study:
- To compare the prognostic performance of CTA and ex-ECG.
- To evaluate their effectiveness in patients with suspected CAD.
Main Methods:
- 681 patients with suspected CAD underwent both ex-ECG and CTA.
- Patients were followed for cardiac events (myocardial infarction, cardiac death, revascularization) and hard cardiac events (excluding revascularization).
Main Results:
- CTA identified CAD with ≥50% stenoses as the sole independent predictor of hard cardiac events in multivariate analysis.
- Positive CTA findings significantly shortened the event-free period, irrespective of ex-ECG results.
- ex-ECG provided additional risk stratification only in patients with positive CTA and low-to-intermediate CAD likelihood.
Conclusions:
- CTA demonstrates higher prognostic value than ex-ECG for suspected CAD.
- CTA is especially beneficial for patients with a low to intermediate pre-test likelihood of CAD.
Objectives:
The aim of the study was to perform a comparison of the prognostic performance of computed tomography coronary angiography (CTA) and exercise electrocardiography (ex-ECG) in patients with suspected coronary artery disease (CAD).
Background:
CAD is a major cause of mortality and morbidity, and its management consumes a large proportion of the health care budget. Therefore, identification of patients at high risk of adverse events is crucial. Despite its limited accuracy, ex-ECG is the most commonly used noninvasive test in CAD evaluation. CTA was recently introduced as alternative test.
Methods:
We enrolled 681 patients (age 61.3 ± 10.4 years, 461 men) with atypical or typical angina and no history of CAD. All patients underwent ex-ECG and CTA and were followed for 44 ±12 months. The endpoints were all cardiac events, defined as nonfatal myocardial infarction, cardiac death, and revascularization, and hard cardiac events, defined as all cardiac events excluding revascularization.
Results:
ex-ECG and CTA were rated as positive in 419 (61%) and 274 (40%) of 681 patients, respectively. In univariate analysis, both ex-ECG and CTA were predictors of all cardiac events (hazard ratio [HR]: 2.09, 95% confidence interval [CI]: 1.5 to 2.8; p < 0.0001 and HR: 21.1, 95% CI: 14.6 to 30.5; p < 0.0001, respectively) and hard cardiac events (HR: 1.9, 95% CI: 1.1 to 3.2; p = 0.02 and HR: 6.8, 95% CI: 3.9 to 11.0; p < 0.0001, respectively), whereas in a multivariate analysis, CAD with ≥50% stenoses detected by CTA was the only independent predictor of hard cardiac events. Stratifying our population by ex-ECG and CTA findings, Kaplan-Meier curves showed that ex-ECG provides only a further risk stratification in the subset of patients with positive findings on CTA and a low to intermediate likelihood of CAD. Moreover, positive findings on CTA identify a shorter event-free period, regardless the ex-ECG findings for both all cardiac events and hard cardiac events, respectively.
Conclusions:
CTA may have a higher prognostic value compared with ex-ECG in patients with suspected CAD, mainly in those with a low to intermediate pre-test likelihood of CAD.
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