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CTCA Prior to Invasive Coronary Angiography in Patients With Previous Bypass Surgery: Patient-Related Outcomes,
Matthew Kelham1,2,3, Anne-Marie Beirne1,2,3, Krishnaraj S Rathod1,2,3
1Centre for Cardiovascular Medicine and Devices, Faculty of Medicine and Dentistry, Queen Mary University of London, United Kingdom (M.K., A.-M.B., K.S.R., M.A., L.W., N.F., R.R., A.B., A.A., A.M., D.A.J.).
Insights
Computed tomography cardiac angiography (CTCA) before invasive coronary angiography (ICA) in bypass surgery patients reduces imaging resource use and major cardiac events long-term. CTCA improves outcomes for patients with prior coronary artery bypass grafting.
Area of Science:
- Cardiology
- Radiology
- Medical Imaging
Background:
- Previous coronary artery bypass grafting (CABG) patients referred for invasive coronary angiography (ICA) present unique diagnostic challenges.
- The BYPASS-CTCA trial initially showed CTCA before ICA reduced procedure time and contrast-associated acute kidney injury.
Purpose of the Study:
- To evaluate the longer-term impact of computed tomography cardiac angiography (CTCA) prior to invasive coronary angiography (ICA) in patients with prior coronary artery bypass grafting.
- To assess patient-related outcomes, diagnostic imaging resource utilization, and major adverse cardiac events (MACE) at 3 years.
Main Methods:
- A randomized controlled trial comparing CTCA before ICA (CTCA+ICA group) versus ICA alone (ICA-only group) in 688 patients with prior CABG.
- Patients were followed for a median of 3 years, with assessments of angina status, quality of life, imaging resource use, and MACE.
Main Results:
- At 3 years, the CTCA+ICA group showed significantly lower imaging resource utilization (35.8% vs. 45.1%) and a reduced incidence of MACE (35.8% vs. 43.5%).
- While initial improvements in angina status and quality of life were observed at 3 months in the CTCA+ICA group, these did not persist long-term.
- No significant differences in patient-related outcomes were noted at the 3-year follow-up.
Conclusions:
- Routine CTCA before ICA in patients with prior CABG is supported by evidence of reduced long-term imaging resource use and MACE.
- CTCA offers a valuable pre-procedural assessment tool, potentially optimizing patient management and resource allocation in this population.
Background:
In patients with previous coronary artery bypass grafting, computed tomography cardiac angiography (CTCA) before invasive coronary angiography (ICA) was demonstrated in the BYPASS-CTCA trial (Randomized Controlled Trial to Assess Whether Computed Tomography Cardiac Angiography Can Improve Invasive Coronary Angiography in Bypass Surgery Patients) to reduce procedure time and incidence of contrast-associated acute kidney injury, with greater levels of patient satisfaction. Patient-related outcomes, utilization of further diagnostic imaging resources, and longer-term incidence of major adverse cardiac events were key secondary end points not yet reported.
Methods:
Patients with prior coronary artery bypass grafting referred for ICA were randomized 1:1 to undergo CTCA before ICA or ICA alone and followed up for a median of 3 (2.2-3.4) years. Angina status was assessed using the Seattle Angina Questionnaire and overall quality of life using the EQ-5D-5L. The incidence of noninvasive imaging use and major adverse cardiac events were compared between the 2 groups.
Results:
In all, 688 patients were randomized, 344 to CTCA+ICA and 344 to ICA only. The mean age of participants was 69.8 years, with 45% undergoing ICA for acute coronary syndromes and the remainder stable angina. At 3 months follow-up, patients in the CTCA+ICA group were more likely to be angina-free (51.7% versus 43.2%; P=0.03) with greater quality of life (EQ-5D-5L index, 81.6 versus 74.4; P=0.001), although these improvements did not persist. At 3 years follow-up, imaging resource use (35.8% versus 45.1%; odds ratio, 0.68 [95% CI, 0.50-0.92]; P=0.013) and incidence of major adverse cardiac events were lower in the CTCA+ICA group (35.8% versus 43.5%; hazard ratio, 0.73 [95% CI, 0.58-0.93]; P=0.010).
Conclusions:
In patients with prior coronary artery bypass grafting undergoing ICA, CTCA before ICA leads to reductions in the use of imaging resources and the rate of major cardiac events out to 3 years, but with similar patient-related outcome measures. Together with the initial findings of BYPASS-CTCA, these data are supportive of routinely undertaking a CTCA before ICA in patients with prior coronary artery bypass grafting.
Registration:
URL: https://www.clinicaltrials.gov; Unique identifier: NCT03736018.
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