Coronary angiography versus coronary computed tomography angiography for coronary artery evaluation in patients with heart failure

Background Current guidelines recommend to exclude coronary artery disease (CAD) in patients with unknown reason of heart failure (HF). Coronary computed tomography angiography (CCTA) and coronary angiography (CAG) are two methods commonly used to identify the coronary artery lesion, but which one is prefer for screening CAD in patients with HF has not been well understood. Purpose This study aimed to compare CCTA versus CAG for screening the coronary artery lesion in patients with left ventricular ejection fraction (LVEF)≤50%. The primary endpoint was the detection of the main branch of coronary artery≥50%. Methods This is a retrospective study enrolled patients with HF with LVEF≤50% from September 2016 to June 2023. Logistic regression was used to analyze the factors associated with the endpoint. A Boruta feature selection approach and a shapely additive explanations (SHAP) with machine learning method were performed to assess the relationship between these factors with the endpoint. Results The mean age of the overall patients (n=579) was 63.78 years, with 70.1% being male. Among the 579 HF patients, 83 patients underwent CCTA imaging, while 496 patients received CAG examination. The overall positive findings was comparable between patients received CCTA and those received CAG (25.5% vs. 26.2%, p=0.862), however, the left circumflex coronary artery lesion was higher in those received CAG (41.5% vs. 14.3%, p=0.017). Patients who underwent percutaneous coronary intervention in CAG group was higher than in CCTA group (7.4% vs. 2.4%, p=0.060); however, it didn’t reach statistical difference. Male gender, concomitant hypertension, diabetes, and advanced age were independent risk factors for a positive coronary screening. This finding was confirmed by Boruta algorithm and SHAP analysis with machine learning method. Conclusion This retrospective study supports prioritizing CCTA for coronary artery disease screening in HF patients without chest pain symptoms due to its minimally invasive advantages. However, for HF patients with hypertension, diabetes, and advanced age, CAD may be preferred, as they are more likely to require coronary intervention.