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Schlattmann P, Wieske V, Bressem KK, Götz T, Schuetz GM, Andreini D, Pontone G, Alkadhi H, Hausleiter J, Zimmermann E, Gerber B, Shabestari AA, Meijs MFL, Sato A, Øvrehus KA, Jenkins SMM, Knuuti J, Hamdan A, Halvorsen BA, Mendoza-Rodriguez V, Rixe J, Wan YL, Langer C, Leschka S, Martuscelli E, Ghostine S, Tardif JC, Sánchez AR, Haase R, Dewey M. The effectiveness of coronary computed tomography angiography and functional testing for the diagnosis of obstructive coronary artery disease: results from the individual patient data Collaborative Meta-Analysis of Cardiac CT (COME-CCT). Insights Imaging 2024; 15:208. [PMID: 39143443 PMCID: PMC11324632 DOI: 10.1186/s13244-024-01702-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/01/2023] [Indexed: 08/16/2024] Open
Abstract
AIM To determine the effectiveness of functional stress testing and computed tomography angiography (CTA) for diagnosis of obstructive coronary artery disease (CAD). METHODS AND RESULTS Two-thousand nine-hundred twenty symptomatic stable chest pain patients were included in the international Collaborative Meta-Analysis of Cardiac CT consortium to compare CTA with exercise electrocardiography (exercise-ECG) and single-photon emission computed tomography (SPECT) for diagnosis of CAD defined as ≥ 50% diameter stenosis by invasive coronary angiography (ICA) as reference standard. Generalised linear mixed models were used for calculating the diagnostic accuracy of each diagnostic test including non-diagnostic results as dependent variables in a logistic regression model with random intercepts and slopes. Covariates were the reference standard ICA, the type of diagnostic method, and their interactions. CTA showed significantly better diagnostic performance (p < 0.0001) with a sensitivity of 94.6% (95% CI 92.7-96) and a specificity of 76.3% (72.2-80) compared to exercise-ECG with 54.9% (47.9-61.7) and 60.9% (53.4-66.3), SPECT with 72.9% (65-79.6) and 44.9% (36.8-53.4), respectively. The positive predictive value of CTA was ≥ 50% in patients with a clinical pretest probability of 10% or more while this was the case for ECG and SPECT at pretest probabilities of ≥ 40 and 28%. CTA reliably excluded obstructive CAD with a post-test probability of below 15% in patients with a pretest probability of up to 74%. CONCLUSION In patients with stable chest pain, CTA is more effective than functional testing for the diagnosis as well as for reliable exclusion of obstructive CAD. CTA should become widely adopted in patients with intermediate pretest probability. SYSTEMATIC REVIEW REGISTRATION PROSPERO Database for Systematic Reviews-CRD42012002780. CRITICAL RELEVANCE STATEMENT In symptomatic stable chest pain patients, coronary CTA is more effective than functional testing for diagnosis and reliable exclusion of obstructive CAD in intermediate pretest probability of CAD. KEY POINTS Coronary computed tomography angiography showed significantly better diagnostic performance (p < 0.0001) for diagnosis of coronary artery disease compared to exercise-ECG and SPECT. The positive predictive value of coronary computed tomography angiography was ≥ 50% in patients with a clinical pretest probability of at least 10%, for ECG ≥ 40%, and for SPECT 28%. Coronary computed tomography angiography reliably excluded obstructive coronary artery disease with a post-test probability of below 15% in patients with a pretest probability of up to 74%.
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Affiliation(s)
- Peter Schlattmann
- Institute of Medical Statistics, Computer Sciences, and Data Science, University Hospital of Friedrich Schiller University Jena, Jena, Germany
| | - Viktoria Wieske
- Department of Radiology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Keno K Bressem
- Department of Radiology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Theresa Götz
- Institute of Medical Statistics, Computer Sciences, and Data Science, University Hospital of Friedrich Schiller University Jena, Jena, Germany
| | - Georg M Schuetz
- Department of Radiology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | | | | | - Hatem Alkadhi
- Institute of Diagnostic and Interventional Radiology University Hospital Zurich, Zurich, Switzerland
| | | | - Elke Zimmermann
- Department of Radiology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Bernhard Gerber
- Department of Cardiology, Clinique Universitaire St Luc, Institut de Recherche Clinique et Expérimentale, Brussels, Belgium
| | - Abbas A Shabestari
- Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Matthijs F L Meijs
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Akira Sato
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | | | | | - Juhani Knuuti
- Turku University Hospital and University of Turku, Turku, Finland
| | - Ashraf Hamdan
- Department of Cardiovascular Imaging, Department of Cardiology, Rabin Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | | | - Johannes Rixe
- Department of Cardiology and Electrophysiology, Jung Stilling Hospital Siegen, Siegen, Germany
| | - Yung-Liang Wan
- Medical Imaging and Radiological Sciences, College of Medicine, Chang Gung University, Chang Gung Memorial Hospital at Linkou, Taoyaun City, Taiwan
| | - Christoph Langer
- Kardiologisch-Angiologische Praxis, Herzzentrum Bremen, Bremen, Germany
| | - Sebastian Leschka
- Department of Radiology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Eugenio Martuscelli
- Department of Internal Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Said Ghostine
- Department of Cardiology, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France
| | | | | | - Robert Haase
- Department of Radiology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Marc Dewey
- Department of Radiology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
- Berlin Institute of Health, Berlin, Germany.
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.
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Wieske V, Walther M, Dubourg B, Alkadhi H, Nørgaard BL, Meijs MFL, Diederichsen ACP, Wan YL, Mickley H, Nikolaou K, Shabestari AA, Halvorsen BA, Martuscelli E, Sun K, Herzog BA, Marcus RP, Leschka S, Garcia MJ, Ovrehus KA, Knuuti J, Mendoza-Rodriguez V, Bettencourt N, Muraglia S, Buechel RR, Kaufmann PA, Zimmermann E, Tardif JC, Budoff MJ, Schlattmann P, Dewey M. Computed tomography angiography versus Agatston score for diagnosis of coronary artery disease in patients with stable chest pain: individual patient data meta-analysis of the international COME-CCT Consortium. Eur Radiol 2022; 32:5233-5245. [PMID: 35267094 PMCID: PMC9279219 DOI: 10.1007/s00330-022-08619-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 01/05/2022] [Accepted: 01/28/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES There is conflicting evidence about the comparative diagnostic accuracy of the Agatston score versus computed tomography angiography (CTA) in patients with suspected obstructive coronary artery disease (CAD). PURPOSE To determine whether CTA is superior to the Agatston score in the diagnosis of CAD. METHODS In total 2452 patients with stable chest pain and a clinical indication for invasive coronary angiography (ICA) for suspected CAD were included by the Collaborative Meta-analysis of Cardiac CT (COME-CCT) Consortium. An Agatston score of > 400 was considered positive, and obstructive CAD defined as at least 50% coronary diameter stenosis on ICA was used as the reference standard. RESULTS Obstructive CAD was diagnosed in 44.9% of patients (1100/2452). The median Agatston score was 74. Diagnostic accuracy of CTA for the detection of obstructive CAD (81.1%, 95% confidence interval [CI]: 77.5 to 84.1%) was significantly higher than that of the Agatston score (68.8%, 95% CI: 64.2 to 73.1%, p < 0.001). Among patients with an Agatston score of zero, 17% (101/600) had obstructive CAD. Diagnostic accuracy of CTA was not significantly different in patients with low to intermediate (1 to < 100, 100-400) versus moderate to high Agatston scores (401-1000, > 1000). CONCLUSIONS Results in our international cohort show CTA to have significantly higher diagnostic accuracy than the Agatston score in patients with stable chest pain, suspected CAD, and a clinical indication for ICA. Diagnostic performance of CTA is not affected by a higher Agatston score while an Agatston score of zero does not reliably exclude obstructive CAD. KEY POINTS • CTA showed significantly higher diagnostic accuracy (81.1%, 95% confidence interval [CI]: 77.5 to 84.1%) for diagnosis of coronary artery disease when compared to the Agatston score (68.8%, 95% CI: 64.2 to 73.1%, p < 0.001). • Diagnostic performance of CTA was not affected by increased amount of calcium and was not significantly different in patients with low to intermediate (1 to <100, 100-400) versus moderate to high Agatston scores (401-1000, > 1000). • Seventeen percent of patients with an Agatston score of zero showed obstructive coronary artery disease by invasive angiography showing absence of coronary artery calcium cannot reliably exclude coronary artery disease.
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Affiliation(s)
- Viktoria Wieske
- Department of Radiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Mario Walther
- Department of Fundamental Sciences, Jena University of Applied Sciences, Jena, Germany
| | - Benjamin Dubourg
- Cardiac Imaging Unit, Department of Radiology, Rouen University Hospital, Rouen, France
| | - Hatem Alkadhi
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Bjarne L Nørgaard
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Matthijs F L Meijs
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Yung-Liang Wan
- Medical Imaging and Radiological Sciences, College of Medicine, Chang Gung University, Chang Gung Memorial Hospital at Linkou, Taoyaun City, Taiwan
| | - Hans Mickley
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Abbas A Shabestari
- Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Eugenio Martuscelli
- Department of Internal Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Kai Sun
- Department of Radiology, Baotou Central Hospital, Baotou, Inner Mongolia Province, China
| | | | - Roy P Marcus
- Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Sebastian Leschka
- Department of Radiology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Mario J Garcia
- Department of Cardiology, Montefiore, University Hospital for the Albert Einstein College of Medicine, New York, NY, USA
| | | | - Juhani Knuuti
- Turku University Hospital and University of Turku, Turku, Finland
| | | | - Nuno Bettencourt
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia, Vila Nova de Gaia, Portugal
| | | | - Ronny R Buechel
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Elke Zimmermann
- Department of Radiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | | | | | - Peter Schlattmann
- Institute of Medical Statistics, Computer Sciences and Data Science, University Hospital of Friedrich Schiller University Jena, Jena, Germany
| | - Marc Dewey
- Department of Radiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
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Yin X, Wang J, Zheng W, Ma J, Hao P, Chen Y. Diagnostic performance of coronary computed tomography angiography versus exercise electrocardiography for coronary artery disease: a systematic review and meta-analysis. J Thorac Dis 2016; 8:1688-96. [PMID: 27499958 DOI: 10.21037/jtd.2016.06.06] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Both coronary computed tomography angiography (CCTA) and exercise electrocardiography (ExECG) are non-invasive testing methods for the evaluation of coronary artery disease (CAD). However, there was controversy on the diagnostic performance of these methods due to the limited data in each single study. Therefore, we performed a meta-analysis to address these issues. METHODS We searched PubMed and Embase databases up to May 22, 2015. Two authors identified eligible studies, extracted data and accessed quality. Pooled estimation of sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), summary receiver-operating characteristic curve (SROC) and the area under curve (AUC) of CCTA and ExECG for the diagnosis of CAD were calculated using Stata, Meta-Disc and Review Manager statistical software. RESULTS Seven articles were included. Pooled sensitivity of CCTA and ExECG were 0.98 [95% confidence intervals (CIs): 0.95-0.99] and 0.66 (95% CIs: 0.59-0.72); pooled specificity of CCTA and ExECG were 0.84 (95% CIs: 0.81-0.87) and 0.75 (95% CIs: 0.71-0.79); pooled DOR of CCTA and ExECG were 110.24 (95% CIs: 35.07-346.55) and 6.28 (95% CIs: 2.06-19.13); and AUC of CCTA and ExECG were 0.9950±0.0046 and 0.7727±0.0638, respectively. There is no heterogeneity caused by threshold effect in CCTA or ExECG analysis. The Deeks' test showed no potential publication bias (P=0.17). CONCLUSIONS CCTA has better diagnostic performance than ExECG in the evaluation of CAD, which can provide a better solution for the clinical problem of the diagnosis for CAD.
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Affiliation(s)
- Xinxin Yin
- Department of Emergency, Qilu Hospital, Shandong University, Jinan 250012, China;; School of Clinical Medicine, Taishan Medical University, Taian 271016, China
| | - Jiali Wang
- Department of Emergency, Qilu Hospital, Shandong University, Jinan 250012, China;; Chest Pain Center, Qilu Hospital, Shandong University, Jinan 250012, China;; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan 250012, China;; Key Laboratory of Cardiovascular Remodeling & Function Research, Chinese Ministry of Education & Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan 250012, China
| | - Wen Zheng
- Department of Emergency, Qilu Hospital, Shandong University, Jinan 250012, China;; Chest Pain Center, Qilu Hospital, Shandong University, Jinan 250012, China;; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan 250012, China;; Key Laboratory of Cardiovascular Remodeling & Function Research, Chinese Ministry of Education & Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan 250012, China
| | - Jingjing Ma
- Department of Emergency, Qilu Hospital, Shandong University, Jinan 250012, China;; Chest Pain Center, Qilu Hospital, Shandong University, Jinan 250012, China;; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan 250012, China;; Key Laboratory of Cardiovascular Remodeling & Function Research, Chinese Ministry of Education & Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan 250012, China
| | - Panpan Hao
- Key Laboratory of Cardiovascular Remodeling & Function Research, Chinese Ministry of Education & Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan 250012, China
| | - Yuguo Chen
- Department of Emergency, Qilu Hospital, Shandong University, Jinan 250012, China;; Chest Pain Center, Qilu Hospital, Shandong University, Jinan 250012, China;; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Qilu Hospital, Shandong University, Jinan 250012, China;; Key Laboratory of Cardiovascular Remodeling & Function Research, Chinese Ministry of Education & Chinese Ministry of Public Health, Qilu Hospital, Shandong University, Jinan 250012, China
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Øvrehus KA, Schuhbaeck A, Marwan M, Achenbach S, Nørgaard BL, Bøtker HE, Dey D. Reproducibility of semi-automatic coronary plaque quantification in coronary CT angiography with sub-mSv radiation dose. J Cardiovasc Comput Tomogr 2016; 10:114-20. [DOI: 10.1016/j.jcct.2015.11.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 10/28/2015] [Accepted: 11/12/2015] [Indexed: 11/25/2022]
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Cardiac CT vs. Stress Testing in Patients with Suspected Coronary Artery Disease: Review and Expert Recommendations. CURRENT CARDIOVASCULAR IMAGING REPORTS 2015; 8. [PMID: 26500716 DOI: 10.1007/s12410-015-9344-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Diagnosis and management of coronary artery disease represent a major challenge to our health care systems affecting millions of patients each year. Until recently, the diagnosis of coronary artery disease could be conclusively determined only by invasive coronary angiography. To avoid risks from cardiac catheterization, many healthcare systems relied on stress testing as gatekeeper for coronary angiography. Advancements in cardiac computed tomography angiography technology now allows to noninvasively visualize coronary artery disease, challenging the role of stress testing as the default noninvasive imaging tool for evaluating patients with chest pain. In this review, we summarize current data on the clinical utility of cardiac computed tomography and stress testing in stable patients with suspected coronary artery disease.
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Ermolao A, Roman F, Gasperetti A, Varnier M, Bergamin M, Zaccaria M. Coronary CT angiography in asymptomatic middle-aged athletes with ST segment anomalies during maximal exercise test. Scand J Med Sci Sports 2015; 26:57-63. [DOI: 10.1111/sms.12404] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2014] [Indexed: 11/28/2022]
Affiliation(s)
- A. Ermolao
- Sport and Exercise Medicine Division; Department of Medicine; University of Padova; Padova Italy
| | - F. Roman
- Sport and Exercise Medicine Division; Department of Medicine; University of Padova; Padova Italy
| | - A. Gasperetti
- Sport and Exercise Medicine Division; Department of Medicine; University of Padova; Padova Italy
| | - M. Varnier
- Sport and Exercise Medicine Division; Department of Medicine; University of Padova; Padova Italy
| | - M. Bergamin
- Sport and Exercise Medicine Division; Department of Medicine; University of Padova; Padova Italy
| | - M. Zaccaria
- Sport and Exercise Medicine Division; Department of Medicine; University of Padova; Padova Italy
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Walther S, Schueler S, Tackmann R, Schuetz GM, Schlattmann P, Dewey M. Compliance with STARD Checklist among Studies of Coronary CT Angiography: Systematic Review. Radiology 2014; 271:74-86. [DOI: 10.1148/radiol.13121720] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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8
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Nielsen LH, Ortner N, Norgaard BL, Achenbach S, Leipsic J, Abdulla J. The diagnostic accuracy and outcomes after coronary computed tomography angiography vs. conventional functional testing in patients with stable angina pectoris: a systematic review and meta-analysis. Eur Heart J Cardiovasc Imaging 2014; 15:961-71. [DOI: 10.1093/ehjci/jeu027] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Linde JJ, Kofoed KF, Sørgaard M, Kelbæk H, Jensen GB, Nielsen WB, Hove JD. Cardiac computed tomography guided treatment strategy in patients with recent acute-onset chest pain. Int J Cardiol 2013; 168:5257-62. [DOI: 10.1016/j.ijcard.2013.08.020] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 07/25/2013] [Accepted: 08/03/2013] [Indexed: 10/26/2022]
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Rüst CA, Knechtle B, Rosemann T. Exercise electrocardiogram testing in two brothers with different outcome - a case study exercise testing in master cyclists. Int J Gen Med 2013; 6:495-501. [PMID: 23825929 PMCID: PMC3698026 DOI: 10.2147/ijgm.s45907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The cases of two brothers training and competing as master cyclists and both preparing for a cycling tour are presented. The older brother aged 66 years went first to the primary care physician and presented with an asymptomatic depression in the exercise stress test of the ST segment in V5 and V6 during recovery after complete exhaustion. Coronary angiography revealed a multi vessel coronary artery disease and he underwent bypass surgery. One year later, he successfully completed his planned cycling tour of ~600 km in seven stages and covering ~12,000 m of total ascent. The younger brother aged 59 years went a few months later to the primary care physician and also performed asymptomatic exercise stress testing without changes in the ST segments. Unfortunately, 2 months later he suffered a cardiac arrest during his cycling tour and survived following immediate successful cardiopulmonary resuscitation on the road by his cycling colleagues. Immediate invasive coronary arteriography showed a complete stenosis of the trunk of arteria coronaria sinistra (left coronary artery), a 40%-50% stenosis of ramus circumflexus, and a 20% stenosis of arteria coronaria dextra (right coronary artery). The left coronary artery was dilated and he continued cycling 2 months later. In both brothers, familial hypercholesterolemia was the main cardiovascular risk factor for the multi vessel coronary artery disease. A negative exercise electrocardiogram in siblings with an increased risk for coronary artery disease seemed not to exclude an advanced multi vessel coronary artery disease. In master athletes with asymptomatic exercise electrocardiogram but a positive family history, further examinations should be performed in order to detect relevant stenosis in coronary arteries.
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Affiliation(s)
- Christoph Alexander Rüst
- Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland
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Methodological quality of diagnostic accuracy studies on non-invasive coronary CT angiography: influence of QUADAS (Quality Assessment of Diagnostic Accuracy Studies included in systematic reviews) items on sensitivity and specificity. Eur Radiol 2013; 23:1603-22. [PMID: 23322410 DOI: 10.1007/s00330-012-2763-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 11/29/2012] [Accepted: 12/10/2012] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To evaluate the methodological quality of diagnostic accuracy studies on coronary computed tomography (CT) angiography using the QUADAS (Quality Assessment of Diagnostic Accuracy Studies included in systematic reviews) tool. METHODS Each QUADAS item was individually defined to adapt it to the special requirements of studies on coronary CT angiography. Two independent investigators analysed 118 studies using 12 QUADAS items. Meta-regression and pooled analyses were performed to identify possible effects of methodological quality items on estimates of diagnostic accuracy. RESULTS The overall methodological quality of coronary CT studies was merely moderate. They fulfilled a median of 7.5 out of 12 items. Only 9 of the 118 studies fulfilled more than 75 % of possible QUADAS items. One QUADAS item ("Uninterpretable Results") showed a significant influence (P = 0.02) on estimates of diagnostic accuracy with "no fulfilment" increasing specificity from 86 to 90 %. Furthermore, pooled analysis revealed that each QUADAS item that is not fulfilled has the potential to change estimates of diagnostic accuracy. CONCLUSIONS The methodological quality of studies investigating the diagnostic accuracy of non-invasive coronary CT is only moderate and was found to affect the sensitivity and specificity. An improvement is highly desirable because good methodology is crucial for adequately assessing imaging technologies. KEY POINTS • Good methodological quality is a basic requirement in diagnostic accuracy studies. • Most coronary CT angiography studies have only been of moderate design quality. • Weak methodological quality will affect the sensitivity and specificity. • No improvement in methodological quality was observed over time. • Authors should consider the QUADAS checklist when undertaking accuracy studies.
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012. [PMID: 23182125 DOI: 10.1016/j.jacc.2012.07.013] [Citation(s) in RCA: 1231] [Impact Index Per Article: 102.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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13
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV, Anderson JL. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:e354-471. [PMID: 23166211 DOI: 10.1161/cir.0b013e318277d6a0] [Citation(s) in RCA: 465] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Schuetz GM, Schlattmann P, Dewey M. Use of 3x2 tables with an intention to diagnose approach to assess clinical performance of diagnostic tests: meta-analytical evaluation of coronary CT angiography studies. BMJ 2012; 345:e6717. [PMID: 23097549 PMCID: PMC3480336 DOI: 10.1136/bmj.e6717] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2012] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To determine whether a 3 × 2 table, using an intention to diagnose approach, is better than the "classic" 2 × 2 table at handling transparent reporting and non-evaluable results, when assessing the accuracy of a diagnostic test. DESIGN Based on a systematic search for diagnostic accuracy studies of coronary computed tomography (CT) angiography, full texts of relevant studies were evaluated to determine whether they could calculate an alternative 3 × 2 table. To quantify an overall effect, we pooled diagnostic accuracy values according to a meta-analytical approach. DATA SOURCES Medline (via PubMed), Embase (via Ovid), and ISI Web of Science electronic databases. ELIGIBILITY CRITERIA Prospective English or German language studies comparing coronary CT with conventional coronary angiography in all patients and providing sufficient data for a patient level analysis. RESULTS 120 studies (10,287 patients) were eligible. Studies varied greatly in their approaches to handling non-evaluable findings. We found 26 studies (including 2298 patients) that allowed us to calculate both 2 × 2 tables and 3 × 2 tables. Using a bivariate random effects model, we compared the 2 × 2 table with the 3 × 2 table, and found significant differences for pooled sensitivity (98.2 (95% confidence interval 96.7 to 99.1) v 92.7 (88.5 to 95.3)), area under the curve (0.99 (0.98 to 1.00) v 0.93 (0.91 to 0.95)), positive likelihood ratio (9.1 (6.2 to 13.3) v 4.4 (3.3 to 6.0)), and negative likelihood ratio (0.02 (0.01 to 0.04) v 0.09 (0.06 to 0.15); (P<0.05)). CONCLUSION Parameters for diagnostic performance significantly decrease if non-evaluable results are included by a 3 × 2 table for analysis (intention to diagnose approach). This approach provides a more realistic picture of the clinical potential of diagnostic tests.
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Affiliation(s)
- Georg M Schuetz
- Department of Radiology, The Charité-Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, Freie Universität Berlin, 10117 Berlin, Germany
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Nielsen LH, Olsen J, Markenvard J, Jensen JM, Nørgaard BL. Effects on costs of frontline diagnostic evaluation in patients suspected of angina: coronary computed tomography angiography vs. conventional ischaemia testing. Eur Heart J Cardiovasc Imaging 2012; 14:449-55. [PMID: 22922828 DOI: 10.1093/ehjci/jes166] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
AIMS The aim of this study was to investigate in patients with stable angina the effects on costs of frontline diagnostics by exercise-stress testing (ex-test) vs. coronary computed tomography angiography (CTA). METHODS AND RESULTS In two coronary units at Lillebaelt Hospital, Denmark, 498 patients were identified in whom either ex-test (n = 247) or CTA (n = 251) were applied as the frontline diagnostic strategy in symptomatic patients with a low-intermediate pre-test probability of coronary artery disease (CAD). During 12 months of follow-up, death, myocardial infarction and costs associated with downstream diagnostic utilization (DTU), treatment, ambulatory visits, and hospitalizations were registered. There was no difference between cohorts in demographic characteristics or the pre-test probability of significant CAD. The mean (SD) age was 56 (11) years; 52% were men; and 96% were at low-intermediate pre-test probability of CAD. All serious cardiac events (n = 3) during follow-up occurred in patients with a negative ex-test result. Mean costs per patient associated with DTU, ambulatory visits, and cardiovascular medication were significantly higher in the ex-test than in the CTA group. The mean (SD) total costs per patient at the end of the follow-up were 14% lower in the CTA group than in the ex-test group, € 1510 (3474) vs. €1777 (3746) (P = 0.03). CONCLUSION Diagnostic assessment of symptomatic patients with a low-intermediate probability of CAD by CTA incurred lower costs when compared with the ex-test. These findings need confirmation in future prospective trials.
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Affiliation(s)
- Lene H Nielsen
- Department of Cardiology, Lillebaelt Hospital, Kabbeltoft 25, 7100 Vejle, Denmark
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Yu ZL, Yang XJ, Zhu JZ, Gu HM, Wang GQ, Hui J, Jiang WP. Using an abnormal increase in postexercise systolic blood pressure to diagnose coronary artery disease in gerontal patients. J Int Med Res 2011; 39:637-46. [PMID: 21672369 DOI: 10.1177/147323001103900233] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Data from 66 patients ≥ 60 years old with suspected coronary artery disease (CAD) were studied to determine the diagnostic value of an abnormal increase in postexercise systolic blood pressure (SBP) for detecting CAD in gerontal patients. Treadmill exercise testing (TET) and selective coronary angiography (CAG) were carried out and SBP was measured pre-TET and at each minute during a 6-min post-TET recovery phase. Abnormal increase in postexercise SBP was defined as a higher SBP compared with that measured earlier during the 6-min post-TET period. An abnormal increase of ≥ 7 mmHg in postexercise SBP had a statistically significantly better specificity, and also showed higher sensitivity and accuracy, than ST-segment depression ≥ 1 mV in identifying gerontal patients with CAD. The combination of ST-segment depression and abnormal SBP resulted in further improvement of the specificity for detecting CAD. It is concluded that measurement of abnormal increase in postexercise SBP may be a sensitive indicator of gerontal CAD.
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Affiliation(s)
- Z L Yu
- Department of Cardiology, Kunshan First People's Hospital Affiliated to Jiangsu University, Kunshan, China.
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Øvrehus KA, Marwan M, Bøtker HE, Achenbach S, Nørgaard BL. Reproducibility of coronary plaque detection and characterization using low radiation dose coronary computed tomographic angiography in patients with intermediate likelihood of coronary artery disease (ReSCAN study). Int J Cardiovasc Imaging 2011; 28:889-99. [PMID: 21626043 DOI: 10.1007/s10554-011-9895-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Accepted: 05/19/2011] [Indexed: 12/12/2022]
Abstract
The purpose of this study is to evaluate the interscan, interobserver and intraobserver agreement for coronary plaque detection, and characterization using low radiation dose high-pitch spiral acquisition coronary CT angiography (CTA). Two experienced observers independently evaluated coronary CTA datasets from 50 consecutive patients undergoing two 128-slice dual source CT scans within 12 days. Mean (±SD) estimated radiation exposure was 1.5 ± 0.2 mSv per scan. Observers recorded the presence and characterization of coronary plaques as non-calcified or calcified. A "segment involvement score" (SIS) was computed by summing the numbers of segments with any coronary plaque per patient. Reproducibility was assessed using kappa (κ) statistics, paired t test and Bland-Altman analyses. Interscan, interobserver, and intraobserver agreement (κ-values) for detection of any or calcified plaques were 83-94% (κ-values 0.57-0.85), and 67-84% (0.31-0.67) for non-calcified plaques on a patient level. No significant difference was observed in mean interscan or interobserver SIS. Mean (95% CI) intraobserver SIS difference was -0.88 (-1.25; -0.51), P < 0.001, with limits of agreement from -4.7 to 2.9. Low radiation dose high-pitch coronary CTA permits detection of any or calcified plaques with high interscan, interobserver, intraobserver agreement. However, variability for the detection of non-calcified plaque is substantial.
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Ovrehus KA, Bøtker HE, Jensen JM, Munkholm H, Johnsen SP, Nørgaard BL. Influence of coronary computed tomographic angiography on patient treatment and prognosis in patients with suspected stable angina pectoris. Am J Cardiol 2011; 107:1473-9. [PMID: 21420047 DOI: 10.1016/j.amjcard.2011.01.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 01/14/2011] [Accepted: 01/18/2011] [Indexed: 01/08/2023]
Abstract
We evaluated the influence of coronary computed tomographic angiography (CTA) as a first-line diagnostic test on patient treatment and prognosis. A total of 1,055 consecutive patients with suspected stable angina pectoris (mean age 55 ± 10 years, 56% women) and a low to intermediate pretest likelihood of coronary artery disease (CAD) were included in the present study. The patients were followed for a median of 18 months. The use of downstream diagnostic testing and medical therapy after CTA were recorded. The CTA result was normal in 49%, and nonobstructive and obstructive CAD (≥50% stenosis) was demonstrated in 31% and 15% of the patients, respectively. Coronary CTA was inconclusive in 5% of the patients. The use of antiplatelet therapy decreased with normal findings from CTA, and the use of antiplatelet and lipid-lowering agents increased in patients with CAD. Additional testing was performed in 2% of patients with normal CTA findings and in 7% and 82% of patients with nonobstructive or obstructive CAD, respectively. No patients without CAD, 0.9% of patients with nonobstructive CAD, and 1.9% of patients with obstructive CAD met the primary end point (cardiovascular death and myocardial infarction, p = 0.008). No patients without CAD, 1.5% of patients with nonobstructive CAD, and 30% patients with obstructive CAD met the secondary end point (cardiovascular death, myocardial infarction, and coronary revascularization, p <0.0001). In conclusion, in patients suspected of having angina, the findings from CTA influence patient treatment without resulting in excessive additional testing. Coronary CTA provides important prognostic information, with excellent intermediate-term outcomes in patients with normal CTA findings.
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Immediate computed tomography coronary angiography versus delayed outpatient stress testing for detecting coronary artery disease in emergency department patients with chest pain. Int J Cardiovasc Imaging 2011; 28:667-74. [PMID: 21503704 DOI: 10.1007/s10554-011-9870-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 04/04/2011] [Indexed: 02/07/2023]
Abstract
Noninvasive testing for coronary artery disease (CAD) is warranted for symptomatic patients with intermediate pretest likelihood of CAD. Accomplishing testing in an emergency department (ED) environment is challenging. We compared two strategies of CAD testing in ED patients: immediate computed tomography coronary angiography (CTCA) versus delayed outpatient stress testing. We conducted a historical control cohort study comparing symptomatic ED patients without an acute coronary syndrome who warranted noninvasive CAD testing. Two cohorts (50 patients each) were defined by CAD testing strategy, immediate CTCA versus delayed stress testing. Outcomes were duration of ED stay, detection of CAD, and 3-month rates of readmission, myocardial infarction, (MI) or death. Median duration of stay was 417.5 minutes (interquartile range [IQR] 359.0-581.0) in the CT cohort and 400.0 minutes (IQR 338.0-471.0) in the control cohort (P = 0.53). CAD was detected in 14 CT cohort patients versus 1 in control (P = 0.0004), due to low follow-up in the control cohort (18 of 50, 36%). Obstructive CAD was diagnosed in 6 CT cohort patients versus 1 in control (P = 0.11). During 3 months of follow-up, four patients in each cohort were reevaluated in the ED for chest pain; no patients suffered MI or death. A strategy of immediate CTCA is superior to a delayed stress testing strategy for detecting CAD in ED patients with chest pain and prompting appropriate referrals for further management. Delayed stress testing was primarily ineffective due to low follow-up. Immediate CTCA can be used safely without altering the ED duration of stay.
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Hecht HS, Gade C. Current and evolving stent evaluation by coronary computed tomographic angiography. Catheter Cardiovasc Interv 2011; 77:843-59. [PMID: 21061254 DOI: 10.1002/ccd.22897] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Accepted: 10/20/2010] [Indexed: 11/12/2022]
Abstract
OBJECTIVES To demonstrate the variety of stent abnormalities that may be evaluated by coronary computed tomographic angiography (CTA). BACKGROUND The application of CTA to the evaluation of coronary stents has focused almost entirely on the detection of in-stent restenosis. METHODS All CTA performed for stent evaluation at a single institution were reviewed. RESULTS In addition to in-stent restenosis, stent fracture, and overlap failure, a multiplicity of stent-related problems not previously addressed by CTA was categorized and illustrated: late stent thrombosis, jailed branches, edge stenosis, bifurcation stents, inadequate stent expansion, stent aneurysms, peri-stent plaque, and stenting into bridged myocardium. CONCLUSIONS CTA may be used to evaluate the full range of stent-related problems. This work provides the framework for future studies validating these applications.
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Affiliation(s)
- Harvey S Hecht
- Lenox Hill Heart and Vascular Institute, Department of Cardiovascular Medicine, New York, New York, USA.
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Frontline diagnostic evaluation of patients suspected of angina by coronary computed tomography reduces downstream resource utilization when compared to conventional ischemia testing. Int J Cardiovasc Imaging 2010; 27:813-23. [DOI: 10.1007/s10554-010-9737-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Accepted: 10/14/2010] [Indexed: 10/18/2022]
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