Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions
Assessing CCTA for Patients with Suspected CAD
JAMA Intern Med; ePub 2017 Oct 2; Foy, et al
When compared with functional stress testing, coronary computed tomography angiography (CCTA) is associated with a reduced incidence of myocardial infarction (MI) in patients with suspected coronary artery disease (CAD), as well as with an increased incidence of invasive coronary angiography, revascularization, CAD diagnoses, and new prescriptions for aspirin and statins. However, CCTA is not associated with a reduction in mortality or cardiac hospitalization. This according to a recent systematic review and meta-analysis of 13 randomized clinical trials of CCTA published from January 1, 2000, to July 10, 2016. Details include:
- There were 10,315 patients in the CCTA arm and 9,777 patients in the functional stress testing arm who were followed up for a mean duration of 18 months.
- CCTA was associated with a reduction in the incidence of MI compared with functional stress testing (0.7% vs 1.1%; RR, 0.71).
- There were no statistically significant differences in death or cardiac hospitalization.
- Patients undergoing CCTA were significantly more likely to undergo invasive coronary angiography and to receive a diagnosis of new CAD and to have initiated aspiring or statin therapy.
Foy AJ, Dhruva SS, Peterson B, Mandrola JM, Morgan DJ, Redberg RF. Coronary computed tomography angiography vs functional stress testing for patients with suspected coronary artery disease. A systematic review and meta-analysis. [Published online ahead of print October 2, 2017]. JAMA Intern Med. doi:10.1001/jamainternmed.2017.4772.
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CCTA and cardiac stress testing are different ways of looking at whether an individual has a significant coronary lesion. CCTA looks at coronary anatomy, and stress testing looks at whether there is functional ischemia. When compared to coronary angiography, CCTA is more accurate than stress testing, which is not surprising, as CCTA measures the same thing as coronary angiography—that is coronary anatomy. The above meta-analysis shows that CCTA is at least as good, and perhaps better, than traditional cardiac stress testing for detecting significant coronary artery lesions that may lead to MI in stable patients who present with new onset chest pain or in patients with an ongoing stable pattern of chest pain. CCTA has been used in both emergency room and outpatient settings to identify patient who need intervention. This study suggests that use in both of these settings is well supported by the data, and while CCTA may decrease by a small amount the incidence of MI, it does not decrease death rate from coronary disease, and either test can be used in the evaluation of patients with suspected coronary disease. —Neil Skolnik, MD