Utility of Cardiac Computed Tomography Angiography to Exclude Clinically Significant Obstructive Coronary Artery Disease in Patients After Myocardial Perfusion Imaging

doi:10.1016/j.amjcard.2011.08.022

The American Journal of Cardiology

Volume 109, Issue 2, 15 January 2012, Pages 165-168

https://doi.org/10.1016/j.amjcard.2011.08.022 Get rights and content

Patients with mildly abnormal or equivocal results on myocardial perfusion imaging (MPI) typically undergo diagnostic angiography or receive medical management for coronary artery disease. Catheterization is often required for either appropriate diagnosis or management. With its very high negative predictive rate, coronary computed tomographic angiography (CCTA) has great potential to rule out clinically significant coronary artery disease in this setting. The aim of this study was to analyze the clinical utility and cost implications of CCTA before invasive angiography in patients with abnormal or equivocal results on MPI. Consecutive patients referred by their physicians to our center with abnormal or equivocal results on MPI were reviewed. Patients with histories of myocardial infarction or of revascularization (coronary artery bypass grafting or percutaneous coronary intervention) were excluded. All patients underwent CCTA. Of 241 participants, only 66 (27%) of the studies with abnormal or equivocal nuclear findings revealed obstructive disease on CCTA (>50% stenosis). Fifty-five of 241 patients had normal coronary arteries, 97 patients had nonsignificant disease (<30%), and 23 patients had mild disease (30% to 50% stenosis) on CCTA, leading to diagnoses of noncardiac chest pain. Selective catheterization (for >50% stenosis on CCTA) demonstrated an average cost reduction of $1,295 per patient. Sensitivity analysis revealed cost savings to be preserved even if up to 70% of the patient cohort underwent catheterization after CCTA and across a wide range of procedural costs. In conclusion, CCTA after equivocal or mild or moderate abnormal MPI findings results in significant cost savings and a robust reduction in the need for cardiac catheterization and excludes obstructive coronary artery disease in almost 75% of patients.

Section snippets

Methods

Consecutive cases involving patients with abnormal or equivocal MPI scans who were referred for CCTA from December 2006 to September 2009 were reviewed. Inclusion criteria were age >40 years and the presence of atypical symptoms with ≥2 cardiac risk factors (hypertension, dyslipidemia, tobacco abuse, obesity, diabetes, and physical inactivity). These patients had to be referred specifically stated to be in lieu of diagnostic angiography. Patients with histories of myocardial infarction or of

Results

A total of 241 patients underwent CCTA for equivocal or abnormal findings on nuclear scans. Fifty-two percent of the cohort (126 of 241) were men, and the average age was 66 ± 11 years. Of the 241 studies performed (Table 1), 55 revealed normal coronary arteries, 97 showed minimal disease (<30%), 23 showed mild disease (30% to 50% stenosis), and 66 showed obstructive disease (>50% stenosis). Overall, 63% of patients with abnormal or equivocal findings on nuclear tests were demonstrated to have

Discussion

In the United States, slightly more than 1/3 of patients without known disease who underwent elective cardiac catheterization had obstructive CAD.⁶ This is similar to our present study, in which only 27% of participants had obstructive disease after equivocal or abnormal findings on nuclear tests. This study shows that using CCTA after equivocal or abnormal results on nuclear stress testing leads to a robust reduction in the need for cardiac catheterization, proving to be safe and cost

References (28)

M.J. Budoff et al.
Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease
J Am Coll Cardiol
(2008)
J.K. Min et al.
Clinical benefits of noninvasive testing: Coronary computed tomography angiography as a test case
J Am Coll Cardiol Img
(2010)
J.H. Cole et al.
Cost implications of initial computed tomography angiography as opposed to catheterization in patients with mildly abnormal or equivocal myocardial perfusion scans
J Cardiovasc Comput Tomogr
(2007)
A.J. Taylor et al.
ACCF/SCCT/ACR/AHA/ASE/ASNC/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography
J Am Coll Cardiol
(2010)
S. Iskander et al.
Risk assessment using single-photon emission computed tomographic technetium-99m sestamibi imaging
J Am Coll Cardiol
(1998)
T.S. Boyne et al.
Predicting adverse outcome with exercise SPECT technetium-99m sestamibi imaging in patients with suspected and known coronary artery disease
Am J Cardiol
(1997)
R.S. Lima et al.
Incremental value of combined perfusion and function over perfusion alone by gated SPECT myocardial perfusion imaging for detection of severe three-vessel coronary artery disease
J Am Coll Cardiol
(2003)
D.S. Berman et al.
Underestimation of extent of ischemia by gated SPECT myocardial perfusion imaging in patients with left main coronary artery disease
J Nucl Cardiol
(2007)
R.A. Harrington et al.
Antithrombotic therapy for coronary artery disease: the seventh ACCP conference on antithrombotic and thrombolytic therapy
Chest
(2004)
W.B. Meijboom et al.
Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study
J Am Coll Cardiol
(2008)

S. Voros et al.

Guideline for minimizing radiation exposure during acquisition of coronary artery calcium scans with the use of multidetector computed tomography: a report by the Society for Atherosclerosis Imaging and Prevention Tomographic Imaging and Prevention Councils in collaboration with the Society of Cardiovascular Computed Tomography

J Cardiovasc Comput Tomogr

(2011)

G.W. Bell et al.

Periprocedural safety of 64-detector row coronary computed tomographic angiography: results from the prospective multicenter ACCURACY trial

J Cardiovasc Comput Tomogr

(2010)

S.S. Halliburton et al.

SCCT guidelines on radiation dose and dose-optimization strategies in cardiovascular CT

J Cardiovasc Comput Tomogr

(2011)

T.Y. Choi et al.

Radiation dose reduction with increasing utilization of prospective gating in 64-multidetector cardiac computed tomography angiography

J Cardiovasc Comput Tomogr

(2011)

Cited by (19)

The lack of obstructive coronary artery disease on coronary CT angiography safely reduces downstream cost and resource utilization during subsequent chest pain presentations
2015, Journal of Cardiovascular Computed Tomography
Citation Excerpt :
Coronary CT angiography (CCTA) has emerged as an effective tool for both outpatient and emergency department (ED) evaluation of low to intermediate risk symptomatic patients.1–6 CCTA has also been shown effective as a complementary test in patients with equivocal or abnormal noninvasive testing.7 With a high negative predictive value (∼99%) for excluding obstructive coronary stenosis, CCTA allows for both a safe and rapid disposition of patients with potential cost savings in the ED setting.8,9
The purpose of this study is to investigate the cost and resource use due to chest pain (CP) evaluations after initial coronary CT angiography (CCTA) stratified by coronary artery disease (CAD) burden.
We examined 1518 patients referred for CCTA from January 2005 to July 2012 for downstream evaluation after CCTA during a median follow-up of 351 days. Results were stratified by CAD burden as quantified on CCTA into no CAD, nonobstructive CAD (<50% stenosis), or obstructive CAD (≥50% stenosis). The incidence of ischemic testing at the time of recurrent evaluation (defined as a composite of clinic visit, emergency department encounter, or ischemic testing after the index CCTA for CP, atypical CP, or angina defined by ICD-9 code), the testing modality used, and frequency of testing were abstracted and used to calculate the direct costs of downstream utilization. Major adverse cardiovascular events defined as all-cause mortality, nonfatal myocardial infarction, stroke, or revascularization >90 days from CCTA were abstracted using ICD-9 codes and Social Security Death Index query.
A total of 174 patients (11.5%) underwent evaluation for CP after index CCTA with a higher rate of subsequent clinical visits among obstructive CAD patients compared to those with nonobstructive CAD and no CAD (17.8% vs 13.9% vs 7.5%; P < .001). A significant reduction in the incidence of repeat ischemic testing was observed in patients with no CAD and nonobstructive CAD (P = .002). This resulted in a lower per-patient cost in the nonobstructive CAD and no CAD patients (median [interquartile range_25–75]: $2952 [$307–2952] and $235 [$0–2880]) when compared with patients with obstructive CAD (median [interquartile range_25–75]: $5832 [$5498–17,459]; P < .001). Major adverse cardiovascular events were not different in the 90 patients that underwent repeat testing at the time of CP evaluation when compared with the 84 patients for whom testing was deferred.
Absence of CAD on initial CCTA was associated with lower costs and decreased downstream utilization compared to the presence of nonobstructive and obstructive CAD on CCTA during median follow-up of 351 days.
Coronary computed tomography as a cost-effective test strategy for coronary artery disease assessment - A systematic review
2014, Atherosclerosis
Citation Excerpt :
For CAD prevalence ≥70%, diagnostic strategies involving ICA, as an initial test may be cost effective for diagnosis of stable chest pain [22]. CCTA is cost-effective strategy when performed as a layering test to equivocal initial stress imaging before performing ICA [33–35]. Use of CCTA may represent a cost- and time-effective strategy for evaluation of low risk (<30% CAD prevalence) acute chest pain patients in the ED [58–61].
Cardiovascular imaging imparts a huge burden on healthcare spending. Coronary CT angiography (CCTA) may provide a cost effective means of diagnosing coronary artery disease (CAD) and reducing downstream cost of testing. We performed a systematic search of literature for randomized controlled trials or prospective or retrospective non-randomized comparative studies or case series, decision analytic models and technology reports in which some or all of the patients underwent CCTA and looking at the cost effectiveness, comparative effectiveness and downstream test utilization associated with the use of CCTA. We found 42 articles matching our criteria. CCTA either as first line or as a layering test may represent a cost effective strategy for initial evaluation of patients with CAD prevalence of 10%–50% in both near-term and long-term diagnostic periods. For CAD prevalence ≥70%, ICA as initial test may represent cost effective strategy for diagnosis of stable chest pain. CCTA may represent cost-effective strategy when performed as a layering test to equivocal initial stress imaging before performing ICA. Use of CCTA is cost- and time-effective strategy for evaluation of low risk (<30% CAD prevalence) acute chest pain patients in emergency department and can be used for safe exclusion of acute coronary syndrome (ACS). Use of coronary calcium score as an initial test may require further evidence to be deemed cost-effective strategy. CCTA may represent a cost effective and may be associated with less downstream testing for diagnosis of stable chest pain patients in low to intermediate risk patients whereas for low risk acute chest pain patients, use of CCTA is associated with expedited patient management, less cost and safe exclusion of ACS.
Long-term prognostic value of stress myocardial perfusion echocardiography in patients with coronary artery disease: a meta-analysis
2021, European Heart Journal Cardiovascular Imaging
Anatomically and functionally relevant coronary stenoses in patients with normal single-photon emission computed tomography but persistent stable angina
2018, European Heart Journal Cardiovascular Imaging
Diagnostic yield and accuracy of coronary CT angiography after abnormal nuclear myocardial perfusion imaging
2018, Scientific Reports
Predictors of severe stenosis at invasive coronary angiography in patients with normal myocardial perfusion imaging
2018, Netherlands Heart Journal

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Coronary artery diseaseUtility of Cardiac Computed Tomography Angiography to Exclude Clinically Significant Obstructive Coronary Artery Disease in Patients After Myocardial Perfusion Imaging

Section snippets

Methods

Results

Discussion

J Am Coll Cardiol

J Am Coll Cardiol Img

J Cardiovasc Comput Tomogr

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Nucl Cardiol

Chest

J Am Coll Cardiol

J Cardiovasc Comput Tomogr

J Cardiovasc Comput Tomogr

J Cardiovasc Comput Tomogr

J Cardiovasc Comput Tomogr

Coronary artery disease
Utility of Cardiac Computed Tomography Angiography to Exclude Clinically Significant Obstructive Coronary Artery Disease in Patients After Myocardial Perfusion Imaging