Selective Referral Using CCTA Versus Direct Referral for Individuals Referred to Invasive Coronary Angiography...

Area of Science:

• Cardiology
• Diagnostic Imaging
• Clinical Trials

Background:

• A significant proportion of patients referred for invasive coronary angiography (ICA) for suspected coronary artery disease (CAD) do not have obstructive stenosis.
• This highlights a need for more efficient diagnostic strategies.

Purpose of the Study:

• To compare the safety and diagnostic yield of a selective referral strategy using coronary computed tomographic angiography (CCTA) versus a direct referral strategy using ICA.
• To evaluate major adverse cardiovascular events (MACE) at 1-year follow-up.

Main Methods:

• A multinational, randomized clinical trial (CONSERVE study) involving 1631 patients referred for non-emergent ICA.
• Patients were randomized to either selective referral (CCTA first) or direct referral (ICA first).
• Primary endpoint was noninferiority of MACE (death, myocardial infarction, unstable angina, stroke, urgent revascularization, cardiac hospitalization) at 1 year.

Main Results:

• Selective referral met noninferiority for MACE (4.6% vs. 4.6%; HR 0.99).
• Only 23% in the selective arm proceeded to ICA, significantly lower than the direct referral arm.
• Coronary revascularization was less frequent in the selective group (13% vs. 18%).
• Rates of normal ICA were significantly lower in the selective arm (24.6% vs. 61.1%).

Conclusions:

• Both selective referral (CCTA-guided) and direct referral strategies are similarly effective in terms of 1-year MACE for stable CAD patients.
• Selective referral significantly reduces ICA utilization and increases diagnostic yield.
• CCTA is an efficient and accurate tool for guiding decisions on performing ICA.