Selective Referral Using CCTA Versus Direct Referral for Individuals Referred to Invasive Coronary Angiography for Suspected CAD A Randomized, Controlled, Open-Label Trial
- Authors
- Chang, Hyuk-Jae; Lin, Fay Y.; Gebow, Dan; An, Hae Young; Andreini, Daniele; Bathina, Ravi; Baggiano, Andrea; Beltrama, Virginia; Cerci, Rodrigo; Choi, Eui-Young; Choi, Jung-Hyun; Choi, So-Yeon; Chung, Namsik; Cole, Jason; Doh, Joon-Hyung; Ha, Sang-Jin; Her, Ae-Young; Kepka, Cezary; Kim, Jang-Young; Kim, Jin-Won; Kim, Sang-Wook; Kim, Woong; Pontone, Gianluca; Valeti, Uma; Villines, Todd C.; Lu, Yao; Kumar, Amit; Cho, Iksung; Danad, Ibrahim; Han, Donghee; Heo, Ran; Lee, Sang-Eun; Lee, Ji Hyun; Park, Hyung-Bok; Sung, Ji-min; Leflang, David; Zullo, Joseph; Shaw, Leslee J.; Min, James K.
- Issue Date
- 7월-2019
- Publisher
- ELSEVIER SCIENCE INC
- Keywords
- coronary computed tomographic angiography; invasive coronary angiography; major adverse cardiac events; stable ischemic heart disease
- Citation
- JACC-CARDIOVASCULAR IMAGING, v.12, no.7, pp.1303 - 1312
- Indexed
- SCIE
SCOPUS
- Journal Title
- JACC-CARDIOVASCULAR IMAGING
- Volume
- 12
- Number
- 7
- Start Page
- 1303
- End Page
- 1312
- URI
- https://scholar.korea.ac.kr/handle/2021.sw.korea/64698
- DOI
- 10.1016/j.jcmg.2018.09.018
- ISSN
- 1936-878X
- Abstract
- OBJECTIVES This study compared the safety and diagnostic yield of a selective referral strategy using coronary computed tomographic angiography (CCTA) compared with a direct referral strategy using invasive coronary angiography (ICA) as the index procedure. BACKGROUND Among patients presenting with signs and symptoms suggestive of coronary artery disease (CAD), a sizeable proportion who are referred to ICA do not have a significant, obstructive stenosis. METHODS In a multinational, randomized clinical trial of patients referred to ICA for nonemergent indications, a selective referral strategy was compared with a direct referral strategy. The primary endpoint was noninferiority with a multiplicative margin of 1.33 of composite major adverse cardiovascular events (blindly adjudicated death, myocardial infarction, unstable angina, stroke, urgent and/or emergent coronary revascularization or cardiac hospitalization) at a median follow-up of 1-year. RESULTS At 22 sites, 823 subjects were randomized to a selective referral and 808 to a direct referral strategy. At 1 year, selective referral met the noninferiority margin of 1.33 (p = 0.026) with a similar event rate between the randomized arms of the trial (4.6% vs. 4.6%; hazard ratio: 0.99; 95% confidence interval: 0.66 to 1.47). Following CCTA, only 23% of the selective referral arm went on to ICA, which was a rate lower than that of the direct referral strategy. Coronary revascularization occurred less often in the selective referral group compared with the direct referral to ICA (13% vs. 18%; p < 0.001). Rates of normal ICA were 24.6% in the selective referral arm compared with 61.1% in the direct referral arm of the trial (p < 0.001). CONCLUSIONS In stable patients with suspected CAD who are eligible for ICA, the comparable 1-year major adverse cardiovascular events rates following a selective referral and direct referral strategy suggests that both diagnostic approaches are similarly effective. In the selective referral strategy, the reduced use of ICA was associated with a greater diagnostic yield, which supported the usefulness of CCTA as an efficient and accurate method to guide decisions of ICA performance. (Coronary Computed Tomographic Angiography for Selective Cardiac Catheterization [CONSERVE]; NCT01810198) Published by Elsevier on behalf of the American College of Cardiology Foundation.
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