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Comprehensive Cardiac CT With Myocardial Perfusion Imaging Versus Functional Testing in Suspected Coronary Artery
Marisa Lubbers1, Adriaan Coenen1, Marcel Kofflard2
1Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
Insights
A tiered cardiac computed tomography (CT) protocol is a faster, more efficient alternative for diagnosing coronary artery disease (CAD) than traditional functional testing, with similar safety outcomes.
Area of Science:
- Cardiology
- Radiology
- Diagnostic Imaging
Background:
- Coronary artery disease (CAD) diagnosis relies on various methods.
- CT angiography accurately rules out CAD but can be enhanced.
- Tiered cardiac CT protocols may improve diagnostic efficiency for angina pectoris.
Purpose of the Study:
- To evaluate the effectiveness, efficiency, and safety of a tiered cardiac CT protocol.
- To compare this protocol against standard functional testing in patients with suspected stable CAD.
Main Methods:
- Prospective randomized trial of 268 patients with stable angina.
- Compared a tiered cardiac CT protocol (calcium scan, CT angiography, CT myocardial perfusion) with functional testing (primarily exercise ECG).
- Assessed endpoints including invasive coronary angiograms without revascularization indication and time to diagnosis.
Main Results:
- The tiered cardiac CT group had fewer invasive angiograms without a revascularization indication (1.5% vs 7.2%).
- Diagnosis was faster with CT (0 days median) compared to functional testing (17 days median).
- CT required less further testing (13% vs 37%) with similar adverse event rates, but higher radiation dose.
Conclusions:
- A tiered cardiac CT protocol, including dynamic perfusion imaging, provides a rapid and efficient diagnostic alternative.
- This approach is effective for patients with suspected stable coronary artery disease.
- The CRESCENT2 trial demonstrated the benefits of this comprehensive cardiac CT strategy.
Objectives:
This study sought to assess the effectiveness, efficiency, and safety of a tiered, comprehensive cardiac computed tomography (CT) protocol in comparison with functional testing.
Background:
Although CT angiography accurately rules out coronary artery disease (CAD), incorporation of CT myocardial perfusion imaging as part of a tiered diagnostic approach could improve the clinical value and efficiency of cardiac CT in the diagnostic work-up of patients with angina pectoris.
Methods:
Between July 2013 and November 2015, 268 patients (mean age 58 years; 49% female) with stable angina (mean pre-test probability 54%) were prospectively randomized between cardiac CT and standard guideline-directed functional testing (95% exercise electrocardiography). The tiered cardiac CT protocol included a calcium scan, followed by CT angiography if calcium was detected. Patients with ≥50% stenosis on CT angiography underwent CT myocardial perfusion imaging.
Results:
By 6 months, the primary endpoint, the rate of invasive coronary angiograms without a European Society of Cardiology class I indication for revascularization, was lower in the CT group than in the functional testing group (2 of 130 [1.5%] vs. 10 of 138 [7.2%]; p = 0.035), whereas the proportion of invasive angiograms with a revascularization indication was higher (88% vs. 50%; p = 0.017). The median duration until the final diagnosis was 0 (0 of 0) days in the CT group and 0 (0 of 17) in the functional testing group (p < 0.001). Overall, 13% of patients randomized to CT required further testing, compared with 37% in the functional testing group (p < 0.001). The adverse event rate was similar (3% vs. 3%; p = 1.000), although the median cumulative radiation dose was higher for the CT group (3.1 mSv [interquartile range: 1.6 to 7.8] vs. 0 mSv [interquartile range: 0.0 to 7.1]; p < 0.001).
Conclusions:
In patients with suspected stable CAD, a tiered cardiac CT protocol with dynamic perfusion imaging offers a fast and efficient alternative to functional testing. (Comprehensive Cardiac CT Versus Exercise Testing in Suspected Coronary Artery Disease 2 [CRESCENT2]; NCT02291484).
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