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Gepubliceerd in: Netherlands Heart Journal 11/2021

Open Access 22-10-2021 | Editor’s Comment

Coronary computed tomographic angiograph as gatekeeper?—The gate is wide open

Auteurs: R. Delewi, I. I. Tulevski

Gepubliceerd in: Netherlands Heart Journal | Uitgave 11/2021

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In the Netherlands, approximately 350,000 patients are referred to a cardiologist for a first evaluation of cardiac complaints. It is estimated that half of this population are assessed for chest pain. As such, there is an ongoing interest in the diagnostic workup of patients with chest pain and suspected coronary artery disease (CAD). In recent years, there have been important technical developments in the field of coronary computed tomographic angiography (CCTA). New trials have been published, and clinical guidelines have advocated a more important role for CCTA in clinical practice. Further advances in hardware and advances analytics will lead to a core role for CCTA at the centre of every clinical cardiovascular practice.
The SCOT-HEART (Scottish Computed Tomography of the Heart Trial) demonstrated the added value of CCTA to standard of care (which included an exercise electrocardiogram in most patients) [1]. The addition of CCTA clarified the diagnosis of angina due to epicardial coronary heart disease. In this trial, the need for further stress testing and invasive coronary angiography was reduced. More focused treatment regimens, as dictated by the cardiologist, were associated with a reduction in fatal and non-fatal myocardial infarction. This effect was largest when the National Institute for Health and Care Excellence criteria were added to the SCOT-HEART cohort, reflecting the patient with atypical and typical angina [2].
The large randomised controlled PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain), which included over 10,000 patients with stable angina pectoris, demonstrated that CCTA was non-inferior to a functional testing approach (MRI, PET/SPECT or stress echocardiography) with respect to the composite endpoint of death, myocardial infarction, hospitalisation for unstable angina or major procedural complications [3]. However, the cost-effectiveness analysis of the PROMISE trial showed that CCTA results in lower costs than functional testing [4]. This is something to consider given the large number of patients who are evaluated for chest pain.
In this issue of the Netherlands Heart Journal, Boerhout et al. argue an even more dominant role for CCTA than used so far in patients with new-onset stable angina presenting at the outpatient clinic [5]. They demonstrate a helpful diagram for the evaluation of chest pain patients, which can be used in daily clinical practice. In fact, in their opinion paper, they propose CCTA as a gatekeeper for all these patients.
In the Cambridge Dictionary, a gatekeeper is described as ‘someone who has the power to decide who gets particular resources and opportunities, and who does not’. In the published flow chart, CCTA will dictate treatment strategy (including medication for primary prevention) and which patient should be referred for further additional noninvasive or invasive testing [5]. Indeed, subanalysis of the PROMISE trial showed a significant improvement of patient compliance to statin therapy in the CCTA arm regardless of CCTA outcome. The lower adherence to statins in the group guided by a functional test (86% in CCTA group vs 67% in functional group) was associated with a higher rate of major adverse cardiac events during the 2 to 5 years of follow-up in the functional group.
However, Boerhout and colleagues add an important notion by suggesting the use of CCTA for the individual patient. In the case of angina with no obstructive coronary artery disease, CCTA cannot discriminate between patients with and without functional disorders of the vessels. CCTA can merely be used to state that there is nonobstructive CAD. The evaluation of symptoms, including the information from CCTA, allows tailored medical treatment. This strategy may reduce the number of invasive procedures, both in nonobstructive and obstructive CAD, if invasive procedures are reserved for those patients who do not respond adequately to installed medical therapy. This means intracoronary function testing in nonobstructive CAD and revascularisation in obstructive CAD.
Therefore, the evaluation conducted by the physician remains the cornerstone of diagnosis and treatment in patients with chest pain and can be regarded as the real gatekeeper for patient management. We are lucky that this is the case, as it makes evaluation in a large number of patients with chest pain an interesting challenge for the medical detectives (MDs).
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creativecommons.​org/​licenses/​by/​4.​0/​.
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Netherlands Heart Journal

Het Netherlands Heart Journal wordt uitgegeven in samenwerking met de Nederlandse Vereniging voor Cardiologie en de Nederlandse Hartstichting. Het tijdschrift is Engelstalig en wordt gratis beschikbaa ...

Literatuur
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go back to reference Newby D, Williams M, Hunter A, et al. CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): An open-label, parallel-group, multicentre trial. Lancet. 2015;385:2383–91. CrossRef Newby D, Williams M, Hunter A, et al. CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): An open-label, parallel-group, multicentre trial. Lancet. 2015;385:2383–91. CrossRef
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go back to reference Adamson PD, Hunter A, Williams MC, et al. Diagnostic and prognostic benefits of computed tomography coronary angiography using the 2016 National Institute for Health and Care Excellence guidance within a randomised trial. Heart. 2018;104:207–14. CrossRef Adamson PD, Hunter A, Williams MC, et al. Diagnostic and prognostic benefits of computed tomography coronary angiography using the 2016 National Institute for Health and Care Excellence guidance within a randomised trial. Heart. 2018;104:207–14. CrossRef
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go back to reference Douglas PS, Hoffmann U, Patel MR, et al. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med. 2015;372:1291–300. CrossRef Douglas PS, Hoffmann U, Patel MR, et al. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med. 2015;372:1291–300. CrossRef
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go back to reference Karády J, Mayrhofer T, Ivanov A, et al. Cost-effectiveness analysis of anatomic vs functional index testing in patients with low-risk stable chest pain. JAMA Netw Open. 2020;3:e2028312. CrossRef Karády J, Mayrhofer T, Ivanov A, et al. Cost-effectiveness analysis of anatomic vs functional index testing in patients with low-risk stable chest pain. JAMA Netw Open. 2020;3:e2028312. CrossRef
Metagegevens
Titel
Coronary computed tomographic angiograph as gatekeeper?—The gate is wide open
Auteurs
R. Delewi
I. I. Tulevski
Publicatiedatum
22-10-2021
Uitgeverij
Bohn Stafleu van Loghum
Gepubliceerd in
Netherlands Heart Journal / Uitgave 11/2021
Print ISSN: 1568-5888
Elektronisch ISSN: 1876-6250
DOI
https://doi.org/10.1007/s12471-021-01640-0