Preventive Management of Nonobstructive CAD After Coronary CT Angiography in the Emergency Department

Honigberg, Michael C.; Lander, Bradley; Baliyan, Vinit; Jones‐O'Connor, Maeve; Healy, Emma; Scholtz, Jan-Erik; Nagurney, John Tobias; Hoffmann, Udo; Ghoshhajra, Brian B.; Natarajan, Pradeep

doi:10.1016/j.jcmg.2019.04.021

Cited by 21 publications

(10 citation statements)

References 37 publications

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“…Initial changes to preventive medication following CCTA in our analysis of the PROMISE trial were similar to those observed in the SCOT-HEART trial, as well as other trials evaluating the impact of coronary artery calcium or carotid plaque screening on preventive medication use. 16 , 25 , 26 , 27 , 28 For example, there was an approximate 20% increase in use of antiplatelet agents after CCTA in the NOCAD group in both the SCOT-HEART and PROMISE trials, as well as minimal change in the use of RAS blockers. 25 The reduced risk of MACE at 5 years in the SCOT-HEART trial has been attributed to this modest increased use of antiplatelet agents and statins in the group with NOCAD identified on CCTA.…”

Section: Discussionmentioning

confidence: 99%

Use of Preventive Medications in Patients With Nonobstructive Coronary Artery Disease: Analysis of the PROMISE Trial

Turgeon

Sedlak

2021

CJC Open

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Background Nonobstructive coronary artery disease (NOCAD) is commonly found on coronary computed tomography angiography (CCTA) during evaluation for coronary artery disease (CAD). There are no guidelines for the medical management of NOCAD, and practice is variable. We aimed to compare patterns of preventive medication use and continuation after identifying NOCAD vs normal coronaries or obstructive CAD on CCTA. Methods We analyzed data from the Pro spective M ulticenter I maging S tudy for E valuation of Chest Pain (PROMISE) trial dataset, restricted to patients with ≥2 follow-up visits after CCTA. We categorized patients as having either obstructive CAD, NOCAD, or normal coronaries. The primary outcome was the proportion of patients reporting continued use of combination preventive medications, defined as a statin, an antithrombotic, and a renin–angiotensin system blocker throughout follow-up after CCTA. Secondary outcomes included the proportion of visits reporting combination therapy and individual medications. Results We included 4388 patients, with a mean follow-up of 2.3 years. Most patients had NOCAD (48.6%), with normal coronaries in 38.9%, and obstructive CAD in 10.1%. Among NOCAD patients, the mean age was 61 years, and 47.2% were women. A total of 9.1% of NOCAD patients continued combination therapy, vs 12.4% with obstructive CAD, and 3.3% with normal coronaries ( P < 0.001), primarily due to lower use of statins and antithrombotic agents. Similarly, patients with obstructive CAD, NOCAD, and normal coronaries reported using combination therapy during a mean of 35%, 24%, and 9% of visits, respectively ( P < 0.001). Conclusions Few patients with NOCAD identified by CCTA used or continued combination preventive cardiovascular medications. Patients with NOCAD represent an at-risk population with potential for optimization of preventive medications.

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Section: Discussionmentioning

confidence: 99%

Use of Preventive Medications in Patients With Nonobstructive Coronary Artery Disease: Analysis of the PROMISE Trial

Turgeon

Sedlak

2021

CJC Open

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“…However, such a CTA finding should prompt adequate preventive or disease modifying therapy and CTA seems to allow for more appropriate use of statins and anti-platelet therapies better than when using non CTA methods for CAD diagnosis. 67,76 CTA can act as an excellent gatekeeper for subsequent decision making in this group and indeed the finding of non-obstructive disease can change preventive management in both non ER 58 and ER 214 settings. This also extends to women with chest pain, a group that has traditionally been under treated e CTA reclassifies more women into the non-CAD category, appropriately decreases down-stream testing, results in similar preventive therapies in both men and women and, more importantly, equal benefit in terms of risk reduction.…”

Section: Role Of Cta For Guiding Further Non-invasive Evaluationmentioning

confidence: 99%

SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography: A Report of the Society of Cardiovascular Computed Tomography

Narula

Chandrashekhar

Ahmadi

et al. 2021

Journal of Cardiovascular Computed Tomography

210

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2.1.2. Diagnostic performance of functional imaging and CTA compared to >50% diameter stenosis by ICA The National Cardiovascular Data Registry 9 suggested that functional testing is suboptimal for detecting significant coronary stenoses. Of the 661,063 patients undergoing elective catheterization, 64% had testing before the invasive coronary angiogram (ICA); of those, only 51.9% were abnormal. The percentages of patients with <50% DS on subsequent ICA ranged from 55 to 56% after an abnormal exercise treadmill test (ETT), stress echocardiography (SE), single photon emission computed tomography (SPECT) and magnetic resonance imaging (MRI); for resting CTA, the percentage was 30%. In the oldest report, Fleischmann et al. evaluated 5874 patients in 41 studies from 1990 to 1997, and reported sensitivity and specificity of 85% and 77% for SE and 87% and 64% for SPECT, with 52% and 71% for exercise ECG. 10 DeJong et al. (Table 2A), in a meta-analysis of 5088 patients in 51 studies from 2000 to 2011 evaluated MRI, SE and SPECT with >50%DS by ICA as reference. 11 MRI was the most sensitive and specific (91% and 80%), with SE (87% and 72%) and SPECT (83% and 77%) roughly similar. Jaarsma et al. (Table 2B), reported on SPECT, MRI and positron emission tomography (PET) in 141 per-patient studies and 70 per-vessel studies. 12 Per-patient diagnostic odds ratio (DOR) was highest for PET (36.47) followed by MRI (26.42) and SPECT (16.31). In pervessel analysis, PET and MRI were equal (24.74 and 24.11), while SPECT was lowest (11.75). In a meta-analysis limited to 26 studies in which CTA was compared to either ETT or SPECT in the same group of patients, Nielsen et al. 13 (Table 2C) reported CTA sensitivities of 95e99%, specificities of 68e93% and DOR of 128e728. Corresponding ranges for ETT were 65e70%, 24e60% and 0.7e4 and for SPECT were 67e73%, 48e52% and 2e4. It is important to understand that available meta-analyses are also challenged by the small numbers of patients in some of the individual reports, potential referral bias, and often include a mixture of newer and older technology (e.g., planar and SPECT imaging). Finally, in a paper published too recently for meta-analysis inclusion, 391 symptomatic patients, 52% with intermediate and 46% with high risk pre-test probability, who were scheduled for ICA, underwent both CTA and SPECT with >50%DS by ICA as reference. 14 Sensitivity, specificity, positive and negative predictive values were 0.92, 0.75, 0.84 and 0.87 for CTA and 0.62, 0.68, 0.74 and 0.55 for SPECT. AUC was significantly higher for CTA (0.91 versus 0.69, p < 0.001.

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“…In addition, coronary CTA has the ability to detect atherosclerosis and therefore impact patient management on a larger scale, although implementation of preventive therapies following CTA in the ED remain suboptimal. 24 The European Society of Cardiology (ESC) guidance for the diagnosis and management of CV disease during the pandemic advocates coronary CTA as the preferred non-invasive imaging modality in patients with acute chest pain and suspected significant CAD, due to its accuracy, short scan time and minimal exposure risk of patients and healthcare team. 25…”

Section: Role Of Coronary Cta In Acute Chest Pain and Elevated Troponmentioning

confidence: 99%

Use of cardiac CT amidst the COVID-19 pandemic and beyond: North American perspective

Singh

Choi

Leipsic

et al. 2021

Journal of Cardiovascular Computed Tomography

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Preventive Management of Nonobstructive CAD After Coronary CT Angiography in the Emergency Department

Cited by 21 publications

References 37 publications

Use of Preventive Medications in Patients With Nonobstructive Coronary Artery Disease: Analysis of the PROMISE Trial

Use of Preventive Medications in Patients With Nonobstructive Coronary Artery Disease: Analysis of the PROMISE Trial

SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography: A Report of the Society of Cardiovascular Computed Tomography

Use of cardiac CT amidst the COVID-19 pandemic and beyond: North American perspective

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