Coronary CT Angiography in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome
Jesper J. LindeHenning KelbækThomas Fritz HansenPer Ejlstrup SigvardsenChristian Torp‐PedersenJan BechMerete HeitmannOlav Wendelboe NielsenDan Eik HøfstenJørgen Tobias KühlIlan RaymondOle Peter KristiansenIda Hastrup SvendsenCharlotte KragelundMartina Chantal de KnegtJens Dahlgaard HoveTem JørgensenRolf SteffensenBirgit JurlanderJawdat AbdullaStig LyngbækHanne ElmingSusette Krohn TherkelsenErik JørgensenLene KløvgaardLia E. BangPeter Riis HansenSteffen HelqvistSøren GalatiusFrants PedersenUlrik AbildgaardPeter ClemmensenKari SaunamäkiLene HolmvangThomas EngstrømGunnar GislasonLars KøberKlaus F. Kofoed
Key result
Coronary CTA had a negative predictive value of 90.9% (95% CI 86.8-94.1%) for ruling out coronary artery stenosis ≥50% in patients with NSTEACS when compared to invasive coronary angiography.
Why the study?
Coronary pathology in NSTEACS patients varies widely, and the ability of coronary CTA to exclude ≥50% coronary artery stenosis needed evaluation.
Does coronary CTA accurately exclude ≥50% coronary artery stenosis in patients with NSTEACS?
Study Design
Type
RCT (n=1,023)
Blinding
Blinded
Randomization
1:1
Structured PICO
Does coronary CTA accurately exclude ≥50% coronary artery stenosis in patients with NSTEACS?
P
Population
1,023 patients with confirmed non-ST-segment elevation acute coronary syndrome who underwent clinically blinded coronary CTA prior to invasive coronary angiography.
I
Intervention
Clinically blinded coronary computed tomography angiography (CTA) conducted prior to invasive coronary angiography.
C
Comparator
Invasive coronary angiography (ICA) as the reference standard.
O
Outcome
Ability of coronary CTA to rule out coronary artery stenosis (≥50% stenosis) in the entire population, expressed as the negative predictive value (NPV).surrogate
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
SAStephan AchenbachCardiologist, Friedrich-Alexander University Erlangen-Nürnberg
“Most importantly, the "50% stenosis threshold" used by the authors is of somewhat limited value when evaluating the accuracy of a diagnostic test in a contemporary trial. Many stenoses estimated to have a diameter reduction of 50% or more are not hemodynamically relevant and clinical decision making, particularly revascularization according to current guidelines, typically would not depend on the mere stenosis threshold.”
“The key thing is that it's pretty much equivalent whether you do an ICA or you do a CT to define the likelihood of events after the MI. So that was kind of reassuring that you don't need to do an ICA if you already have a CT.”
“The most benefit of CT would lie in the patients with high-risk coronary anatomy and the highest likelihood of receiving revascularization. Our idea was if you could preselect patients in whom you think that revascularization would provide the highest likelihood of benefit, so they wouldn't need the risk of having an invasive procedure, that would kind of be a very nice way of optimizing the treatment strategy.”
Implication
Coronary CTA has a high negative predictive value and sensitivity for ruling out ≥50% coronary artery stenosis in patients with NSTEACS, suggesting its potential utility as an initial non-invasive diagnostic strategy.
Abstract
BACKGROUND In patients with non-ST-segment elevation acute coronary syndrome (NSTEACS), coronary pathology may range from structurally normal vessels to severe coronary artery disease. OBJECTIVES The purpose of this study was to test if coronary computed tomography angiography (CTA) may be used to exclude coronary artery stenosis ≥50% in patients with NSTEACS. METHODS The VERDICT (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography in Patients With Acute Coronary Syndromes) trial (NCT02061891) evaluated the outcome of patients with confirmed NSTEACS randomized 1:1 to very early (within 12 h) or standard (48 to 72 h) invasive coronary angiography (ICA). As an observational component of the trial, a clinically blinded coronary CTA was conducted prior to ICA in both groups. The primary endpoint was the ability of coronary CTA to rule out coronary artery stenosis (≥50% stenosis) in the entire population, expressed as the negative predictive value (NPV), using ICA as the reference standard. RESULTS Coronary CTA was conducted in 1,023 patients-very early, 2.5 h (interquartile range [IQR]: 1.8 to 4.2 h), n = 583; and standard, 59.9 h (IQR: 38.9 to 86.7 h); n = 440 after the diagnosis of NSTEACS was made. A coronary stenosis ≥50% was found by coronary CTA in 68.9% and by ICA in 67.4% of the patients. Per-patient NPV of coronary CTA was 90.9% (95% confidence interval [CI]: 86.8% to 94.1%) and the positive predictive value, sensitivity, and specificity were 87.9% (95% CI: 85.3% to 90.1%), 96.5% (95% CI: 94.9% to 97.8%) and 72.4% (95% CI: 67.2% to 77.1%), respectively. NPV was not influenced by patient characteristics or clinical risk profile and was similar in the very early and the standard strategy group. CONCLUSIONS Coronary CTA has a high diagnostic accuracy to rule out clinically significant coronary artery disease in patients with NSTEACS.
Discussion
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Cite This Study
Linde et al. (2020) conducted an RCT in Non-ST-segment elevation acute coronary syndrome (NSTEACS) (n=1,023). Coronary computed tomography angiography (CTA) vs. Invasive coronary angiography (ICA) was evaluated on Ability of coronary CTA to rule out coronary artery stenosis (≥50% stenosis) expressed as the negative predictive value (NPV), using ICA as the reference standard (95% CI 86.8-94.1). Coronary CTA had a negative predictive value of 90.9% (95% CI 86.8-94.1%) for ruling out coronary artery stenosis ≥50% in patients with NSTEACS when compared to invasive coronary angiography.