Searching for the optimal strategy for the diagnosis of stable coronary artery disease. Cost-effectiveness of the new algorithm (original) (raw)
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Routine use of coronary computed tomography as initial diagnostic test for angina pectoris
Archives of Cardiovascular Diseases, 2011
Background. -Coronary computed tomography (CCT) detects coronary obstruction with high sensitivity and might be useful for diagnosis of angina pectoris. Aim. -In this pilot study, we sought to prospectively evaluate the performance of CCT as initial work up and determine the significance of this strategy according to the pretest likelihood of having coronary artery disease (CAD). Methods. -One hundred and eighty patients with chest discomfort and suspected angina were prospectively referred for CCT with a 64-slice CT scan. Invasive coronary angiography (ICA) was performed on the basis of CCT findings (stenosis > 50%). Patients were classified into tertiles according to estimated pretest probability of obstructive CAD using the Duke Clinical Score (low, intermediate and high). Strategy failure was defined as unnecessary ICA or major adverse cardiac event (MACE) within 6 months in patients without significant stenosis by CCT.
2020
Worldwide the health expenditures as a percentage of each national gross domestic product continue to rise. Cardiovascular diseases as part of the noncommunicable disease group, according to the World Health Organization and the most important scientific associations, are growing due to the aging of the population and the increase of cardiovascular risk factors, due to the epidemiologic as well as to the health transition, especially in the developing countries, which account for the majority of the population in the world (Lopez et al., 2006). In the last few decades we witnessed a proliferation of diagnostic tests to evaluate cardiac heart diseases and in particular coronary artery disease (CAD): exercise stress test, transthoracic echocardiography, stress echocardiography, stress single photon emission computed tomography, myocardial perfusion imaging, magnetic resonance, fractional flow reserve, electron beam computed tomography. Each diagnostic test, which continuously evolves due to technological improvements, proved to have a high sensibility, specificity and good accuracy in identifying symptomatic as well asymptomatic CAD patients. All these tests are however unable to give us information about the anatomy of the coronary arteries, which is essential to provide a treatment that goes beyond the medical treatment and in particular when cardiac surgery is needed. In fact catheter angiography or invasive coronary angiography (ICA), since its introduction in the second half of last century, was the only test able to visualize, in vivo, the coronary tree and to provide images of the coronary artery anatomy upon which both cardiologists and surgeons decide if a patient should be revascularized or medically treated. With time ICA increased its performance due to the improvement in its software and hardware (quantitative coronary angiography, flat panel digital detectors), and due to the introduction of important tools which can be used routinely like intravascular coronary ultrasound, that for the first time visualized, in vivo, the presence of non calcified plaques and vessel's positive remodeling. There are other interesting tools that can be associated to ICA, but, for the moment, are the armamentarium of some specialized centers and mainly used for research purposes like elastography, spectroscopy, angioscopy, thermography and optical coherence thermography. www.intechopen.com Coronary Angiography-Advances in Noninvasive Imaging Approach for Evaluation of Coronary Artery Disease 200 All this data places ICA as the "reference" technique or "gold standard" technique to study the anatomy of coronary arteries. ICA has been widely employed to validate the results obtained with functional procedures, even though the anatomical findings of ICA are also judged by functional tests (Winchester et al., 2010). These interdependence of validation shows how a technique, even ICA, cannot be considered the unique "gold standard" technique to study CAD patients. In fact clinicians while studying their patients have to consider more than one question (diagnostic question, prognostic question, therapeutic question) and ICA alone is unable to give an exhaustive answer to all these questions (Mark et al., 2010). This is the reason why we are in search for technologies to evaluate CAD patients and in particular to study the anatomy of their coronary arteries keeping in mind that these new tests have to be feasible, able to compete with ICA in providing accurate information and, last but not least, economically affordable.
Revista portuguesa de cardiologia : orgão oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology : an official journal of the Portuguese Society of Cardiology, 2013
The purpose of this study was to assess the change in theoretical probability of coronary artery disease (CAD) in patients with suspected CAD undergoing coronary CT angiography (CCTA) as first line test vs. patients who underwent CCTA after an exercise ECG. Pre- and post-test probabilities of CAD were assessed in 158 patients with suspected CAD undergoing dual-source CCTA as the first-line test (Group A) and in 134 in whom CCTA was performed after an exercise ECG (Group B). Pre-test probabilities were calculated based on age, gender and type of chest pain. Post-test probabilities were calculated according to Bayes' theorem. There were no significant differences between the groups regarding pre-test probability (median 23.5% [13.3-37.8] in group A vs. 20.5% [13.4-34.5] in group B; p=0,479). In group A, the percentage of patients with intermediate likelihood of disease (10-90%) was 90% before testing and 15% after CCTA (p<0,001), while in group B, it was 95% before testing, 87%...
International Journal of Cardiology, 2013
Background: Although conventional (CAG) and computed tomography angiography (CTA) are reliable diagnostic modalities for exclusion of obstructive coronary artery disease (CAD), they are costly and with considerable exposure to radiation and contrast media. We compared the accuracy of coronary calcium scanning (CCS) and exercise electrocardiography (X-ECG) as less expensive and non-invasive means to rule out obstructive CAD. Methods: In a rapid-access chest pain clinic, 791 consecutive patients with stable chest pain were planned to undergo X-ECG and dual-source CTA with CCS. According to the Duke pre-test probability of CAD patients were classified as low (b 30%), intermediate (30-70%) or high risk (N 70%). Angiographic obstructive CAD (N 50% stenosis by CAG or CTA) was found in 210/791 (27%) patients, CAG overruling any CTA results. Results: Obstructive CAD was found in 12/281 (4%) patients with no coronary calcium and in 73/319 (23%) with a normal X-ECG (p b 0.001). No coronary calcium was associated with a substantially lower likelihood ratio compared to X-ECG; 0.11, 0.13 and 0.13 vs. 0.93, 0.55 and 0.46 in the low, intermediate and high risk group. In low risk patients a negative calcium score reduced the likelihood of obstructive CAD to less than 5%, removing the need for further diagnostic work-up. CCS could be performed in 754/756 (100%) patients, while X-ECG was diagnostic in 448/756 (59%) patients (p b 0.001). Conclusions: In real-world patients with stable chest pain CCS is a reliable initial test to rule out obstructive CAD and can be performed in virtually all patients.
The American Journal of Cardiology, 2013
We assessed the performance of a new-generation, 256-row computed tomography (CT) scanner for detection of obstructive coronary artery disease (CAD) compared to invasive quantitative coronary angiography. A total 121 consecutive symptomatic patients without known CAD referred for invasive coronary angiography (age 59 -12 years, 37% women) underwent clinically driven 256-row coronary computed tomographic angiography (CCTA) before the invasive procedure. Obstructive CAD (>50% diameter stenosis) was assessed visually on CCTA by 2 independent observers using the 18-segment society of cardiovascular CT model and on invasive angiograms using quantitative coronary angiography (the reference standard). Observers were unaware of the findings from the alternate modality. Nonassessable coronary computed tomographic angiographic segments were considered obstructive for the purpose of analysis. Quantitative coronary angiography demonstrated obstructive CAD in 145 segments in 82 of 121 patients (68%). Overall, 1,677 coronary segments were available for comparative analysis, of which 39 (2.3%) were nonassessable by CCTA, mostly because of heavy calcification. Patient-based and segmentbased analysis showed a sensitivity of 100% and 97% (95% confidence interval 95% to 100%) and specificity of 69% (95% confidence interval 55% to 84%) and 97% (confidence interval 96% to 98%), respectively. Four segments with obstructive CAD in 4 patients were not detected by CCTA. All 4 patients had additional coronary obstructions identified by CCTA. The predictive accuracy was 90% (range 85% to 95%) for patient based and 97% (96% to 98%) for segment based analysis. In conclusion, 256-row CCTA showed high sensitivity and high predictive accuracy for detection of obstructive CAD in patients without previously known disease. Although coronary calcification might still interfere with analysis, the rate of nonassessable segments was low. Ó 2013 Elsevier Inc. All rights reserved. (Am J Cardiol 2013;111:510e515)
2019
Introduction: Exercise tolerance test (ETT) is an established screening test for coronary artery disease (CAD), but not feasible in 30−40% of patients. Dobutamine stress echocardiography (DSE) is an excellent alternative. Traditionally, inducible worsening of wall motion by 1 grade from baseline provides an index of CAD; worsening by 2 grade or more theoretically represents a more severe perfusion abnormality. The present study represents the inaugural experience of DSE at the National Institute of Cardiovascular Disease, Dhaka. Objective: To assess the predictive accuracy of DSE results with the presence and extent of CAD in subjects with suspected stable angina pectoris. Materials and Methods: In this prospective observational study, 35 subjects with intermediate to high probability of CAD were subjected to DSE followed by coronary angiography (CAG) within one month. Comparison of DSE results and predicted coronary artery involvement with angiographic findings were done. Overall s...