title: On the inappropriateness of noninvasive multidetector computed tomography coronary angiography to trigger coronary revascularization: a comparison with invasive angiography.
abstract: OBJECTIVE
  Our purpose was to evaluate the appropriateness of multidetector computed tomography angiography (MDCTA) as an anatomical standard for decision making in patients with known or suspected coronary artery disease.
  
  
  BACKGROUND
  Although correlative studies between MDCTA and coronary angiography (CA) show good agreement, MDCTA visualizes plaque burden and calcifications well before luminal dimensions are encroached.
  
  
  METHODS
  Pressure-derived fractional flow reserve (FFR) was obtained in 81 patients (116 vessels) who underwent both CA and MDCTA. Segments were visually graded for stenosis severity as: G0 = normal, G1 = nonobstructive (<50% diameter reduction), and G2 = obstructive (> or =50% diameter reduction).
  
  
  RESULTS
  Concordance between segmental severity scores by MDCTA and CA was good (k = 0.74; 95% confidence interval: 0.56 to 0.92). Diagnostic performance of MDCTA for detection of functionally significant stenosis based on FFR was low (sensitivity 79%; specificity 64%; positive likelihood ratio 2.2; negative likelihood ratio 0.3). Revascularization was considered appropriate in the presence of reduced FFR (< or =0.75). Decision making based on MDCTA guidance would result in revascularization in the absence of ischemia in 22% of patients (18 of 81) and inappropriate deferral in 7% (6 of 81), while revascularization in the absence of ischemia would be 16% (13 of 81) and inappropriate deferral 12% (10 of 81) with decisions guided by CA. Combined evaluation of stenosis severity using both anatomy (with either CA or MDCTA) and function (with FFR) yields the highest proportion of appropriate decisions: 90% and 91%, respectively (p = 0.0001 vs. CA only, p = 0.0001 vs. MDCTA only).
  
  
  CONCLUSIONS
  Similar to CA, anatomical assessment of coronary stenosis severity by MDCTA does not reliably predict its functional significance.
authors.affiliation: Cardiovascular Center, OLV Hospital, Aalst, Belgium.
authors.forename: Giovanna
authors.initials: G
authors.lastname: Sarno
authors.forename: Isabel
authors.initials: I
authors.lastname: Decraemer
authors.forename: Piet K
authors.initials: PK
authors.lastname: Vanhoenacker
authors.forename: Bernard
authors.initials: B
authors.lastname: De Bruyne
authors.forename: Michalis
authors.initials: M
authors.lastname: Hamilos
authors.forename: Thomas
authors.initials: T
authors.lastname: Cuisset
authors.forename: Eric
authors.initials: E
authors.lastname: Wyffels
authors.forename: Jozef
authors.initials: J
authors.lastname: Bartunek
authors.forename: Guy R
authors.initials: GR
authors.lastname: Heyndrickx
authors.forename: William
authors.initials: W
authors.lastname: Wijns
mesh_terms: D000368:Aged; D017023:Coronary Angiography / Q000379:methods*; D023921:Coronary Stenosis / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000601:surgery; D005260:Female; D053805:Fractional Flow Reserve, Myocardial; D006801:Humans; D016013:Likelihood Functions; D008297:Male; D008875:Middle Aged; D009204:Myocardial Revascularization; D018579:Patient Selection; D011237:Predictive Value of Tests; D011446:Prospective Studies; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed; D019564:Unnecessary Procedures