Functional compared to anatomical imaging in the initial evaluation of patients with suspected coronary artery disease: An international, multi-center, randomized controlled trial (IAEA-SPECT/CTA study)

Noninvasive imaging modalities in coronary artery disease: a meta analysis comparing coronary computed tomography angiography and standard of care

Introduction: Coronary artery disease has become a global pandemic and a major cause of death. The risk-factor calculation for coronary artery damage is an invasive procedure. Aim: To compare coronary computed tomography angiography (CCTA) with standard of care (SOC) to calculate need for revascularization, invasive coronary angiography as well as for myocardial infarction (MI) incidence and all-cause mortality. Methodology, results & conclusion: CCTA is significantly correlated with a reduction in MI episodes (RR = 0.752, 95% CI = 0.578-1.409; p < 0.033) and an increase in revascularizations (RR = 1.401, 95% CI = 1.315-1.492; p < 0.001) and invasive coronary angiography procedures (RR = 1.304, 95% CI = 1.208-1.409; p < 0.001). However, it was found that it did not affect all-cause mortality. On the contrary, standard care approaches were associated with greater rates of MI but lesser referrals for invasive coronary angiography and revascularization.

Diagnostic Strategies for the Assessment of Suspected Stable Coronary Artery Disease : A Systematic Review and Meta-analysis

BACKGROUND

There is uncertainty about which diagnostic strategy for detecting coronary artery disease (CAD) provides better outcomes.

PURPOSE

To compare the effect on clinical management and subsequent health effects of alternative diagnostic strategies for the initial assessment of suspected stable CAD.

DATA SOURCES

PubMed, Embase, and Cochrane Central Register of Controlled Trials.

STUDY SELECTION

Randomized clinical trials comparing diagnostic strategies for CAD detection among patients with symptoms suggestive of stable CAD.

DATA EXTRACTION

Three investigators independently extracted study data.

DATA SYNTHESIS

The strongest available evidence was for 3 of the 6 comparisons: coronary computed tomography angiography (CCTA) versus invasive coronary angiography (ICA) (4 trials), CCTA versus exercise electrocardiography (ECG) (2 trials), and CCTA versus stress single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) (5 trials). Compared with direct ICA referral, CCTA was associated with no difference in cardiovascular death and myocardial infarction (relative risk [RR], 0.84 [95% CI, 0.52 to 1.35]; low certainty) but less index ICA (RR, 0.23 [CI, 0.22 to 0.25]; high certainty) and index revascularization (RR, 0.71 [CI, 0.63 to 0.80]; moderate certainty). Moreover, CCTA was associated with a reduction in cardiovascular death and myocardial infarction compared with exercise ECG (RR, 0.66 [CI, 0.44 to 0.99]; moderate certainty) and SPECT-MPI (RR, 0.64 [CI, 0.45 to 0.90]; high certainty). However, CCTA was associated with more index revascularization (RR, 1.78 [CI, 1.33 to 2.38]; moderate certainty) but less downstream testing (RR, 0.56 [CI, 0.45 to 0.71]; very low certainty) than exercise ECG. Low-certainty evidence compared SPECT-MPI versus exercise ECG (2 trials), SPECT-MPI versus stress cardiovascular magnetic resonance imaging (1 trial), and stress echocardiography versus exercise ECG (1 trial).

LIMITATION

Most comparisons primarily rely on a single study, many studies were underpowered to detect potential differences in direct health outcomes, and individual patient data were lacking.

CONCLUSION

For the initial assessment of patients with suspected stable CAD, CCTA was associated with similar health effects to direct ICA referral, and with a health benefit compared with exercise ECG and SPECT-MPI. Further research is needed to better assess the relative performance of each diagnostic strategy.

PRIMARY FUNDING SOURCE

None. (PROSPERO: CRD42022329635).

Impact of design characteristics among studies comparing coronary computed tomography angiography to noninvasive functional testing in chronic coronary syndromes

BACKGROUND

Coronary computed tomography angiography (CCTA) is widely adopted to detect obstructive coronary artery disease (CAD) in patients with chronic coronary syndromes (CCS). However, it is unknown to which extent study-specific characteristics yield different conclusions.

METHODS

We summarized non-randomized and randomized studies comparing CCTA and noninvasive functional testing for CCS with information on the outcome of myocardial infarction (MI). We evaluated the differential effect according to study characteristics using random-effect meta-analysis with Hartung-Knapp-Sidik-Jonkman adjustments.

RESULTS

Fifteen studies (8 non-randomized, 7 randomized) were included. CCTA was associated with decrease in relative (odds ratio (OR) 0.54, 95%CI 0.47 to 0.62, P < .001) and absolute MI risk (risk difference (RD) -0.4%, 95%CI -0.6 to -0.1, P = .005). The results remained consistent among the non-randomized (RD -0.4%, 95%CI -0.7 to -0.1, P=.029), but not among the randomized trials where there was no difference in the observed risk (RD 0.2%, 95%CI -0.6 to 0.1, P = .158). CCTA was not associated with MI reduction in studies with clinical outcome definition (OR 0.77, 95%CI 0.41 to 1.44, P = .212), research driven follow-up (OR 0.54, 95%CI 0.24 to 1.21, P = .090), central event assessment (OR 0.63, 95%CI 0.21 to 1.86, P = .207), outcome adjudication (OR 0.74, 95%CI 0.24 to 2.23, P = .178), or at low-risk of bias (OR 0.74, 95%CI 0.24 to 2.23, P = .178).

CONCLUSIONS

Among studies of any design, CCTA was associated with lower risk of MI in CCS compared to noninvasive functional testing. This benefit was diminished among studies with clinical outcome definition, central outcome assessment/adjudication or at low-risk of bias.

Current Concepts and Future Applications of Non-Invasive Functional and Anatomical Evaluation of Coronary Artery Disease

Over the last decades, significant advances have been achieved in the treatment of coronary artery disease (CAD). Proper non-invasive diagnosis and appropriate management based on functional information and the extension of ischemia or viability remain the cornerstone in the fight against adverse CAD events. Stress echocardiography and single photon emission computed tomography are often used for the evaluation of ischemia. Advancements in non-invasive imaging modalities such as computed tomography (CT) coronary angiography and cardiac magnetic resonance imaging (MRI) have not only allowed non-invasive imaging of coronary artery lumen but also provide additional functional information. Other characteristics regarding the plaque morphology can be further evaluated with the latest modalities achieving a morpho-functional evaluation of CAD. Advances in the utilization of positron emission tomography (PET), as well as software advancements especially regarding cardiac CT, may provide additional prognostic information to a more evidence-based treatment decision. Since the armamentarium on non-invasive imaging modalities has evolved, the knowledge of the capabilities and limitations of each imaging modality should be evaluated in a case-by-case basis to achieve the best diagnosis and treatment decision. In this review article, we present the most recent advances in the noninvasive anatomical and functional evaluation of CAD.

Noninvasive diagnostic modalities for the diagnosis of coronary artery disease: A guide for acute care NPs

ABSTRACT

Selecting noninvasive diagnostic tests for coronary artery disease can be a daunting task to acute care NPs. This article provides an overview of the pathophysiology of coronary artery disease, relevant noninvasive diagnostic imaging modalities, and an evidence-based approach to guide subsequent diagnostic and therapeutic interventions.

Poor outcome among patients undergoing myocardial perfusion imaging with intermediate-zone troponin

BACKGROUND

Intermediate zone troponin elevation is defined as one to five times the upper limit of normal. Approximately half the patients presenting with chest pain to the emergency department have initial intermediate zone troponin.

OBJECTIVES

We aimed to investigate the long-term outcome of patients hospitalized with chest pain and intermediate zone troponin elevation.

METHODS

We investigated 8269 patients hospitalized in a tertiary center with chest pain. All patients had serial measurements of troponin during hospitalization. Patients were divided into three groups based on their initial troponin levels: negative troponin (N = 6112), intermediate zone troponin (N = 1329) and positive troponin (N = 828). All patients underwent myocardial perfusion imaging (MPI) as part of the initial evaluation.

RESULTS

Mean age of the study population was 68 ± 11, of whom 36% were women. Patients with an intermediate zone troponin were older, more likely to be males, and with significantly more cardiovascular co-morbidities. Multivariate analysis adjusted for age, gender, cardiovascular risk factors, and abnormal MPI result found that patients with intermediate zone troponin had a 70% increased risk of re-hospitalization at 1 year (HR 1.70, 95%CI 1.48-1.96, p-value < 0.001) and 5.3 times higher risk of total mortality at 1-year (HR 5.33, 95%CI 3.65-7.78, p-value < 0.001). sub-group analysis found that among the intermediate zone troponin group, patients with double intermediate zone troponin had the poorest outcome.

CONCLUSIONS

Intermediate zone troponin elevation is an independent risk factor associated with adverse outcomes and therefore patients with an initial value in this range should be closely monitored and aggressively managed.

Computed tomography coronary angiography as the noninvasive in stable coronary artery disease? Long-term outcomes meta-analysis

Aim: To compare outcomes of coronary computed tomography angiography (CCTA) with that of functional testing (FT) in stable coronary artery disease. Methods: We searched PubMed, Embase, and Cochrane for randomized controlled trials (RCTs). A random-effects meta-analysis targeting all-cause death and nonfatal acute coronary syndromes was performed. Results: Eight RCTs enrolling 29,579 patients were included. Pooled relative risk (RR) for the primary end point was similar between CCTA and FT (RR = 0.97; 95% CI: 0.76-1.22). CCTA outperformed FT in nonfatal myocardial infarction (MI) (RR = 0.59; 95% CI: 0.41-0.83) and in downstream testing (OR: 0.47; 95% CI: 0.21-1.01). Conclusion: Updated data of stable coronary artery disease suggests that CCTA improved nonfatal MI and downstream testing.

Coronary Computed Tomographic Angiography for Complete Assessment of Coronary Artery Disease: JACC State-of-the-Art Review

Coronary computed tomography angiography (CTA) has shown great technological improvements over the last 2 decades. High accuracy of CTA in detecting significant coronary stenosis has promoted CTA as a substitute for conventional invasive coronary angiography in patients with suspected coronary artery disease. In patients with coronary stenosis, CTA-derived physiological assessment is surrogate for intracoronary pressure and velocity wires, and renders possible decision-making about revascularization solely based on computed tomography. Computed tomography coronary anatomy with functionality assessment could potentially become a first line in diagnosis. Noninvasive imaging assessment of plaque burden and morphology is becoming a valuable substitute for intravascular imaging. Recently, wall shear stress and perivascular inflammation have been introduced. These assessments could support risk management for both primary and secondary cardiovascular prevention. Anatomy, functionality, and plaque composition by CTA tend to replace invasive assessment. Complete CTA assessment could provide a 1-stop-shop for diagnosis, risk management, and decision-making on treatment.

ESC 2019 guidelines for the diagnosis and management of chronic coronary syndromes : Recommendations for cardiovascular imaging

The European Society of Cardiology (ESC) has recently published new guidelines on the diagnosis and management of chronic coronary syndromes (CCS). Due to variable symptoms, objective tests are often necessary to confirm the diagnosis, exclude alternative diagnoses, and assess the severity of underlying disease. This review provides a summary of the main diagnostic strategies listed in the guidelines for evaluation of patients suspected of having obstructive coronary artery disease (CAD). Based on data from contemporary cohorts of patients referred for diagnostic testing, the pre-test probabilities of obstructive CAD based on age, sex, and symptoms have been adjusted substantially downward compared with the previous guidelines. Further, a new concept of “clinical likelihood of CAD” was introduced accounting for the impact of various risk factors and modifiers on the pre-test probability. Noninvasive functional imaging for myocardial ischemia, coronary computed tomography angiography, or invasive coronary angiography combined with functional evaluation is recommended as the initial strategy to diagnose CAD in symptomatic patients, unless obstructive CAD can be excluded by clinical assessment alone. When available, imaging tests are recommended as noninvasive modalities instead of exercise electrocardiograms.

Impact of International Atomic Energy Agency support to the development of nuclear cardiology in low-and-middle-income countries: Case of Latin America and the Caribbean

Cardiovascular diseases (CVDs) are the leading cause of death in Latin America and the Caribbean (LAC) region as well as worldwide. Lifestyle, nutritional habits and the upsurge of obesity have contributed to the increase in the prevalence of CVDs in the region. The role of nuclear cardiology in the management of patients with CVDs is well established. Particularly, myocardial perfusion imaging is widely used in LAC countries and has been increasingly integrated into the healthcare systems in the region for the diagnosis of coronary artery disease, risk stratification and to guide patient management. In its role to support countries around the world to address their health needs through the peaceful applications of nuclear techniques, the International Atomic Energy Agency (IAEA) has provided assistance to the LAC region for the establishment and strengthening of the nuclear cardiology practice. To that extent, the IAEA provides support in building capacities of multidisciplinary teams of professionals, the provision of medical equipment and the promotion of communication and exchange of knowledge among the different stakeholders. In addition, the IAEA encourages the participation of nuclear medicine centers in international multi-center research studies. In this paper, we present some of the projects through which the IAEA has supported the LAC region, including regional technical cooperation projects and coordinated research projects related to cardiology within the current multimodality approach to cardiac imaging.

Imaging in ESC clinical guidelines: chronic coronary syndromes

The European Society of Cardiology (ESC) has recently published new guidelines on the diagnosis and management of chronic coronary syndromes (CCS). The 2019 guideline identified six common clinical scenarios of CCS defined by the different evolutionary phases of coronary artery disease (CAD), excluding the situations in which an acute coronary event, often with coronary thrombus formation, dominates the clinical presentation. This review aims at providing a summary of novel or revised concepts in the guidelines together with the recent data underlying the major changes on the use of cardiac imaging in patients with suspected or known CCS.

Based on data from contemporary cohorts of patients referred for diagnostic testing, the pre-test probabilities of CAD based on age, sex and symptoms have been adjusted substantially downward as compared with 2013 ESC guidelines. Further, the impact of various risk factors and modifiers on the pre-test probability was highlighted and a new concept of ‘Clinical likelihood of CAD’ was introduced. Recommendations regarding diagnostic tests to establish or rule-out obstructive CAD have been updated with recent data on their diagnostic performance in different patient groups and impact on patient outcome. As the initial strategy to diagnose CAD in symptomatic patients, non-invasive functional imaging for myocardial ischaemia, coronary computed tomography angiography or invasive coronary angiography combined with functional evaluation may be used, unless obstructive CAD can be excluded by clinical assessment alone. When available, imaging tests instead of the exercise electrocardiogram are recommended when following the non-invasive diagnostic strategy.

Review of cardiovascular imaging in the Journal of Nuclear Cardiology in 2017. Part 2 of 2: Myocardial perfusion imaging

In 2017, the Journal of Nuclear Cardiology published many high-quality articles. In this review, we will summarize a selection of these articles to provide a concise review of the main advancements that have recently occurred in the field. In the first article of this 2-part series, we focused on publications dealing with positron emission tomography, computed tomography, and magnetic resonance. This review will place emphasis on myocardial perfusion imaging using single-photon emission computed tomography summarizing advances in the field including prognosis, safety and tolerability, the impact of imaging on management, and the use of novel imaging protocols.

Cardiac CT in the Emergency Department: Contrasting Evidence from Registries and Randomized Controlled Trials

PURPOSE OF REVIEW

To compare outcomes between registries and randomized controlled trials of coronary computed tomographic angiography (CCTA)-based versus standard of care approaches to the initial evaluation of patients with acute chest pain.

RECENT FINDINGS

Randomized trials have demonstrated CCTA to be a safe and efficient tool for triage of low- to intermediate-risk patients presenting to the emergency department with chest pain. Recent studies demonstrate heterogeneous result using different standard of care approaches for evaluation of hard endpoints in comparison with standard evaluation. Also, there has been continued concern for increase in subsequent testing after coronary CTA. Although CCTA improves detection of coronary artery disease, it is uncertain if it will bring improvement of long-term health outcomes at this point of time. Careful analysis of the previous results and further investigation will be required to validate evaluation of hard endpoints.

Outcomes of non-invasive diagnostic modalities for the detection of coronary artery disease: network meta-analysis of diagnostic randomised controlled trials

OBJECTIVE

To evaluate differences in downstream testing, coronary revascularisation, and clinical outcomes following non-invasive diagnostic modalities used to detect coronary artery disease.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

Medline, Medline in process, Embase, Cochrane Library for clinical trials, PubMed, Web of Science, SCOPUS, WHO International Clinical Trials Registry Platform, and Clinicaltrials.gov.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Diagnostic randomised controlled trials comparing non-invasive diagnostic modalities in patients presenting with symptoms suggestive of low risk acute coronary syndrome or stable coronary artery disease.

DATA SYNTHESIS

A random effects network meta-analysis synthesised available evidence from trials evaluating the effect of non-invasive diagnostic modalities on downstream testing and patient oriented outcomes in patients with suspected coronary artery disease. Modalities included exercise electrocardiograms, stress echocardiography, single photon emission computed tomography-myocardial perfusion imaging, real time myocardial contrast echocardiography, coronary computed tomographic angiography, and cardiovascular magnetic resonance. Unpublished outcome data were obtained from 11 trials.

RESULTS

18 trials of patients with low risk acute coronary syndrome (n=11 329) and 12 trials of those with suspected stable coronary artery disease (n=22 062) were included. Among patients with low risk acute coronary syndrome, stress echocardiography, cardiovascular magnetic resonance, and exercise electrocardiograms resulted in fewer invasive referrals for coronary angiography than coronary computed tomographic angiography (odds ratio 0.28 (95% confidence interval 0.14 to 0.57), 0.32 (0.15 to 0.71), and 0.53 (0.28 to 1.00), respectively). There was no effect on the subsequent risk of myocardial infarction, but estimates were imprecise. Heterogeneity and inconsistency were low. In patients with suspected stable coronary artery disease, an initial diagnostic strategy of stress echocardiography or single photon emission computed tomography-myocardial perfusion imaging resulted in fewer downstream tests than coronary computed tomographic angiography (0.24 (0.08 to 0.74) and 0.57 (0.37 to 0.87), respectively). However, exercise electrocardiograms yielded the highest downstream testing rate. Estimates for death and myocardial infarction were imprecise without clear discrimination between strategies.

CONCLUSIONS

For patients with low risk acute coronary syndrome, an initial diagnostic strategy of stress echocardiography or cardiovascular magnetic resonance is associated with fewer referrals for invasive coronary angiography and revascularisation procedures than non-invasive anatomical testing, without apparent impact on the future risk of myocardial infarction. For suspected stable coronary artery disease, there was no clear discrimination between diagnostic strategies regarding the subsequent need for invasive coronary angiography, and differences in the risk of myocardial infarction cannot be ruled out.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registry no CRD42016049442.

Review of cardiovascular imaging in the Journal of Nuclear Cardiology 2017. Part 1 of 2: Positron emission tomography, computed tomography, and magnetic resonance

Several original articles and editorials have been published in the Journal of Nuclear Cardiology in 2017. It has become a tradition at the beginning of each year to summarize some of these key articles in 2 sister reviews. In this first part one, we will discuss some of the progress made in the field of heart failure (cardio-oncology, myocardial blood flow, viability, dyssynchrony, and risk stratification), inflammation, molecular and hybrid imaging using advancement in positron emission tomography, computed tomography, and magnetic resonance imaging.

Comparison of mid- to long-term clinical outcomes between anatomical testing and usual care in patients with suspected coronary artery disease: A meta-analysis of randomized trials

BACKGROUND

Controversies remain regarding clinical outcomes following initial strategies of coronary computed tomography angiography (CCTA) vs usual care with functional testing in patients with suspected coronary artery disease (CAD).

HYPOTHESIS

CCTA as initial diagnostic strategy results in better mid- to long-term outcomes than usual care in patients with suspected CAD.

METHODS

We searched PubMed, Embase, and Cochrane Library for randomized controlled trials comparing clinical outcomes during ≥6 months' follow-up between initial anatomical testing by CCTA vs usual care with functional testing in patients with suspected CAD. Occurrence of all-cause mortality, nonfatal myocardial infarction (MI), and major adverse cardiovascular events (MACE), and use of invasive coronary angiography and coronary revascularization, were compared between the 2 diagnostic strategies.

RESULTS

Twelve trials were included (20 014 patients; mean follow-up, 20.5 months). Patients undergoing CCTA as initial noninvasive testing had lower risk of nonfatal MI compared with those treated with usual care (risk ratio [RR]: 0.70, 95% confidence interval [CI]: 0.52-0.94, P = 0.02). There was a tendency for reduced MACE following initial CCTA strategy, but not for risk of all-cause mortality. Compared with functional testing, the CCTA strategy increased use of invasive coronary angiography (RR: 1.53, 95% CI: 1.12-2.09, P = 0.007) and coronary revascularization (RR: 1.49, 95% CI: 1.11-2.00, P = 0.007).

CONCLUSIONS

Anatomical testing with CCTA as the initial noninvasive diagnostic modality in patients with suspected CAD resulted in lower risk of nonfatal MI than usual care with functional testing, at the expense of more frequent use of invasive procedures.

Acute chest pain evaluation using coronary computed tomography angiography compared with standard of care: a meta-analysis of randomised clinical trials

Objective

Coronary CT angiography (CCTA) has certain advantages compared with stress testing including greater accuracy in identifying obstructive coronary disease. The aim of the study was to perform a systematical review and meta-analysis comparing CCTA with other standard-of-care (SOC) approaches in evaluation of patients with acute chest pain.

Methods

Electronic databases were systematically searched to identify randomised clinical trials of patients with acute chest pain comparing CCTA with SOC approaches. We examined the following end points: mortality, major adverse cardiac events (MACE), myocardial infarction (MI), invasive coronary angiography (ICA) and revascularisation. Pooled risk ratios (RR) and their 95% CIs were calculated using random-effects models.

Results

Ten trials with 6285 patients were included. The trials used different definitions and implementation for SOC but all used physiologic testing. The clinical follow-up ranged from 1 to 19 months. There were no significant differences in all-cause mortality (RR 0.48, 95% CI 0.17 to 1.36, p=0.17), MI (RR 0.82, 95% CI 0.49 to 1.39, p=0.47) or MACE (RR 0.98, 95% CI 0.67 to 1.43, p=0.92) between the groups. However, significantly higher rates of ICA (RR 1.32, 95% CI 1.07 to 1.63, p=0.01) and revascularisation (RR 1.77, 95% CI 1.35 to 2.31, p<0.0001) were observed in the CCTA arm.

Conclusions

Compared with other SOC approaches use of CCTA is associated with similar major adverse cardiac events but higher rates of revascularisation in patients with acute chest pain.

Functional versus anatomical approach in stable coronary artery disease patients: Perspective of low- and middle-income countries

Coronary artery disease (CAD) is the primary cause of death worldwide. Nevertheless, while mortality rates have decreased over the last decades in high-income countries, in many low- and middle-income countries, the situation is just the opposite. Thus, the utilization of the more rational approach to diagnose, risk-stratify, and guide cost-effective management in these patients is of utmost importance in a setting of limited financial resources. Topics such as function versus anatomy with the focus on prognosis in stable CAD patients, as well as future perspectives on noninvasive techniques, will be addressed.