Coronary CTA optimized with nitroglycerin and beta-blockers demonstrated 100% per-patient sensitivity and 100% NPV compared to invasive coronary angiography in severe aortic stenosis.
Cohort (n=327)
Yes
Does CTA and FFRCT optimized with nitroglycerin and beta-blockers safely and accurately assess coronary artery disease in patients with severe aortic stenosis referred for TAVR?
Coronary CTA with FFRCT optimized with nitroglycerin and beta-blockers is safe and highly accurate for assessing CAD in stable severe AS patients, potentially reducing the need for routine invasive angiography before TAVR.
Background Coronary artery disease (CAD) is common in patients with severe aortic stenosis (AS) and may impact transcatheter aortic valve replacement (TAVR) procedural and long-term outcomes. CT coronary angiography (CTA) and CT-derived fractional flow reserve (FFR CT ) are tools used to assess CAD. However, adoption in the TAVR population is hindered by safety concerns with nitroglycerin and beta-blockers. The safety, accuracy, and utility of CTA and FFR CT optimised with these medications for TAVR have not been established. Methods This international, multi-center, prospective registry included severe AS patients referred for TAVR, assessed for CAD with CTA and FFR CT . Patients all received nitroglycerin and beta-blockers as needed to optimise image quality. Severe ventricular dysfunction, recent syncope/heart failure, critical hemodynamics, or prior revascularization were excluded. Significant CAD was defined as CTA stenosis ≥50 % and FFR CT ≤0.75. Primary endpoint was per-patient sensitivity and negative predictive value (NPV) of CTA compared to invasive coronary angiography (ICA). Secondary endpoints included specificity and positive predictive value (PPV) of CTA and FFR CT , safety, feasibility (non-evaluable rate), and the modelled potential of CTA + FFR CT to reduce pre-TAVR ICA. Results 327 patients (75.9 ± 9.7 years, 53 % male) underwent CTA. CTA was safe and well tolerated in nearly all patients, with transient hypotension in 4 (1.2 %). CTA was evaluable in 326 patients (99.7 %), with 9 (2.8 %) having a non-evaluable vessel. FFR CT and ICA were performed in 110 (33.6 %) and 133 (40.7 %) patients, respectively. Per-patient sensitivity, specificity, NPV, and PPV of CTA were 100 %, 71.4 %, 100 %, and 75.9 % and per-vessel 82.7 %, 78.9 %, 92.3 %, and 59.9 %. FFR CT improved specificity and PPV to 88.9 % and 88.0 % for per-patient and 95.1 % and 81.8 % for per-vessel analysis. Using a simulated triage model deferring ICA in patients with CTA 0.75, 267 patients (81.7 %) could potentially have avoided ICA. Conclusion Coronary CTA performed with nitroglycerin and selective use of beta-blockers is safe and effective for assessing CAD in stable severe AS patients. Combining CTA and FFR CT enhances diagnostic accuracy, potentially reducing the need for invasive angiography and streamlining TAVR workup.
Ihdayhid et al. (Tue,) conducted a cohort in Severe aortic stenosis (n=327). Coronary CTA and FFR CT optimized with nitroglycerin and beta-blockers vs. Invasive coronary angiography (ICA) was evaluated on Per-patient sensitivity and negative predictive value (NPV) of CTA compared to invasive coronary angiography (ICA). Coronary CTA optimized with nitroglycerin and beta-blockers demonstrated 100% per-patient sensitivity and 100% NPV compared to invasive coronary angiography in severe aortic stenosis.