CT Angiography Followed by Invasive Angiography in Patients With Moderate or Severe Ischemia-Insights From the ISCHEMIA Trial

• Authors: John GB Mancini, The University of British Columbia; Jonathan Leipsic, The University of British Columbia; Matthew J Budoff, The Lundquist Institute; Cameron J Hague, The University of British Columbia; James K Min, Cleerly, Inc., New York; Susanna R Stevens, Duke Clinical Research Institute; Harmony R Reynolds, NYU Grossman School of Medicine; Sean M O'Brien, Duke Clinical Research Institute; Leslee Shaw, Emory University; Cholenahally N Manjunath, Sri Jayadeva Institute of Cardiovascular Sciences and Research; Kreton Mavromatis, Emory University; Marcin Demkow, Instytut Kardiologii im. Prymasa Tysiaclecia Stefana Kardynała Wyszynskiego; Jose Luis Lopez-Sendon, Instituto de Investigación Sanitaria del Hospital Universitario La Paz; Alexander M Chernavskiy, Ministry of Health of Russian Federation; Gilbert Gosselin, Institut de Cardiologie de Montreal; Herwig Schuchlenz, LKH-Universitätsklinikum Graz; Gerard P Devlin, Gisborne Hospital; Anoop Chauhan, Blackpool Teaching Hospitals NHS Foundation Trust; Sripal Bangalore, NYU Grossman School of Medicine; Judith S Hochman, NYU Grossman School of Medicine; David J Maron, Stanford University School of Medicine
• Journal Title: JACC: Cardiovascular Imaging
• Volume: Volume 14, Number 7
• Publisher: Elsevier B.V | 2021-07-01, Pages 1384-1393
• Type of Work: Article | Post-print: After Peer Review
• Publisher DOI: http://doi.org/10.1016/j.jcmg.2020.11.012
• Subjects: Health Sciences, Public Health; Health Sciences, Health Care Management; Health Sciences, Medicine and Surgery
• Keywords: cardiac catheterization; cardiac computed tomographic angiography; invasive coronary angiography; ischemia; left main coronary artery disease; Angiography; Computed Tomography Angiography; Humans; Ischemia; Predictive Value of Tests

Abstract

Objectives: This study aimed to examine the concordance of coronary computed tomographic angiography (CCTA) assessment of coronary anatomy and invasive coronary angiography (ICA) as the reference standard in patients enrolled in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches). Background: Performance of CCTA compared with ICA has not been assessed in patients with very high burdens of stress-induced ischemia and a high likelihood of anatomically significant coronary artery disease (CAD). A blinded CCTA was performed after enrollment to exclude patients with left main (LM) disease or no obstructive CAD before randomization to an initial conservative or invasive strategy, the latter guided by ICA and optimal revascularization. Methods: Rates of concordance were calculated on a per-patient basis in patients randomized to the invasive strategy. Anatomic significance was defined as ≥50% diameter stenosis (DS) for both modalities. Sensitivity analyses using a threshold of ≥70% DS for CCTA or considering only CCTA images of good-to-excellent quality were performed. Results: In 1,728 patients identified by CCTA as having no LM disease ≥50% and at least single-vessel CAD, ICA confirmed 97.1% without LM disease ≥50%, 92.2% with at least single-vessel CAD and no LM disease ≥50%, and only 4.9% without anatomically significant CAD. Results using a ≥70% DS threshold or only CCTA of good-to-excellent quality showed similar overall performance. Conclusions: CCTA before randomization in ISCHEMIA demonstrated high concordance with subsequent ICA for identification of patients with angiographically significant disease without LM disease.