Coronary computed tomographic angiography as a gatekeeper to invasive diagnostic and surgical procedures: results from the multicenter CONFIRM (Coronary CT Angiography Evaluation for Clinical Outcomes: an International Multicenter) registry.
OBJECTIVE
This study sought to examine patterns of follow-up invasive coronary angiography (ICA) and revascularization (REV) after coronary computed tomography angiography (CCTA).


BACKGROUND
CCTA is a noninvasive test that permits direct visualization of the extent and severity of coronary artery disease (CAD). Post-CCTA patterns of follow-up ICA and REV are incompletely defined.


METHODS
We examined 15,207 intermediate likelihood patients from 8 sites in 6 countries; these patients were without known CAD, underwent CCTA, and were followed up for 2.3 ± 1.2 years for all-cause mortality. Coronary artery stenosis was judged as obstructive when ≥50% stenosis was present. A multivariable logistic regression was used to estimate ICA use. A Cox proportional hazards model was used to estimate all-cause mortality.


RESULTS
During follow-up, ICA rates for patients with no CAD to mild CAD according to CCTA were low (2.5% and 8.3%), with similarly low rates of REV (0.3% and 2.5%). Most ICA procedures (79%) occurred ≤3 months of CCTA. Obstructive CAD was associated with higher rates of ICA and REV for 1-vessel (44.3% and 28.0%), 2-vessel (53.3% and 43.6%), and 3-vessel (69.4% and 66.8%) CAD, respectively. For patients with <50% stenosis, early ICA rates were elevated; over the entirety of follow-up, predictors of ICA were mild left main, mild proximal CAD, respectively, or higher coronary calcium scores. In patients with <50% stenosis, the relative hazard for death was 2.2 (p = 0.011) for ICA versus no ICA. Conversely, for patients with CAD, the relative hazard for death was 0.61 for ICA versus no ICA (p = 0.047).


CONCLUSIONS
These findings support the concept that CCTA may be used effectively as a gatekeeper to ICA.
Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA. leslee.shaw@emory.edu
Leslee J
LJ
Shaw
Jörg
J
Hausleiter
Stephan
S
Achenbach
Mouaz
M
Al-Mallah
Daniel S
DS
Berman
Matthew J
MJ
Budoff
Fillippo
F
Cademartiri
Tracy Q
TQ
Callister
Hyuk-Jae
HJ
Chang
Yong-Jin
YJ
Kim
Victor Y
VY
Cheng
Benjamin J W
BJ
Chow
Ricardo C
RC
Cury
Augustin J
AJ
Delago
Allison L
AL
Dunning
Gudrun M
GM
Feuchtner
Martin
M
Hadamitzky
Ronald P
RP
Karlsberg
Philipp A
PA
Kaufmann
Jonathon
J
Leipsic
Fay Y
FY
Lin
Kavitha M
KM
Chinnaiyan
Erica
E
Maffei
Gilbert L
GL
Raff
Todd C
TC
Villines
Troy
T
Labounty
Millie J
MJ
Gomez
James K
JK
Min
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017023:Coronary Angiography / Q000379:methods*; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging* / Q000401:mortality; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009204:Myocardial Revascularization / Q000379:methods* / Q000401:mortality; D011379:Prognosis; D016016:Proportional Hazards Models; D012042:Registries; D018570:Risk Assessment; D012720:Severity of Illness Index; D015996:Survival Rate; D014057:Tomography, X-Ray Computed / Q000379:methods*