Comparative safety and effectiveness of coronary computed tomography: Systematic review and meta-analysis including 11 randomized controlled trials and 19,957 patients

2022 use of coronary computed tomographic angiography for patients presenting with acute chest pain to the emergency department: An expert consensus document of the Society of cardiovascular computed tomography (SCCT): Endorsed by the American College of Radiology (ACR) and North American Society for cardiovascular Imaging (NASCI)

Coronary computed tomography angiography (CTA) improves the quality of care for patients presenting with acute chest pain (ACP) to the emergency department (ED), particularly in patients with low to intermediate likelihood of acute coronary syndrome (ACS). The Society of Cardiovascular Computed Tomography Guidelines Committee was formed to develop recommendations for acquiring, interpreting, and reporting of coronary CTA to ensure appropriate, safe, and efficient use of this modality. Because of the increasing use of coronary CTA testing for the evaluation of ACP patients, the Committee has been charged with the development of the present document to assist physicians and technologists. These recommendations were produced as an educational tool for practitioners evaluating acute chest pain patients in the ED, in the interest of developing systematic standards of practice for coronary CTA based on the best available data or broad expert consensus. Due to the highly variable nature of medical care, approaches to patient selection, preparation, protocol selection, interpretation or reporting that differs from these guidelines may represent an appropriate variation based on a legitimate assessment of an individual patient's needs.

Oral antiplatelet therapy in the elderly undergoing percutaneous coronary intervention: an umbrella review

Percutaneous coronary intervention has become a mainstay in the management of coronary artery disease. While initially advanced age was considered a relative contraindication to invasive management of coronary artery disease, current cardiovascular practice stands solidly on an early invasive approach for elderly patients, typically based on radial access and drug-eluting stent implantation. Since the advent of coronary stents, oral antiplatelet therapy has proved crucial to maximize the benefits and minimize the risks of stenting, and this holds even truer in older patients rather than in younger ones. Indeed, the elderly is typically at higher risk of thrombotic events as well as bleeding complications, and thus careful decision making must be exercised to prescribe the most appropriate antiplatelet regimen. We thus conducted an umbrella review with scoping purposes on oral antiplatelet therapy in elderly patients undergoing percutaneous coronary intervention, retrieving 8 pertinent systematic reviews. We found that, while several drugs are available, ranging from aspirin to cilostazol, clopidogrel, dipyridamole, prasugrel, ticagrelor, and ticlopidine, most commonly a dual antiplatelet therapy comprising aspirin and a P2Y12 inhibitor is recommended, with subtle adjustments for pretreatment, loading, dose, duration, escalation or de-escalation, with the potential adjunct in selected patients of novel oral anticoagulants. Indeed, a flexible and individualized approach to oral antiplatelet therapy in elderly patients undergoing percutaneous coronary intervention is paramount, factoring patient features (exploiting thrombotic, bleeding and frailty scores), triage (including when appropriate non-invasive assessment of anatomic and functional significance of coronary artery disease), angiographic and other invasive imaging features, interventional technique, stent choice, rehabilitation, and secondary prevention.

Hybrid anatomo-functional imaging of coronary artery disease: Beneficial irrespective of its core components

Coronary artery disease (CAD) is the most common and important cause of ischemic heart disease, with major implications on global morbidity and mortality. Non-invasive testing is crucial in the diagnostic and prognostic work-up of patients with or at risk of CAD, and also to guide decision making in terms of pharmacologic and revascularization therapy. The traditional paradigm is to view anatomic (i.e., coronary computed tomography) and functional imaging (e.g., myocardial perfusion scintigraphy) tests as opposing alternatives. Such approach is too reductionist and does not capitalize on the strengths of each type of test while risking to overlook the inherent limitations. The combination of anatomic and functional tests in a logic of hybrid imaging holds the promise of overcoming the limitations inherent to anatomic and functional testing, enabling more accurate diagnosis, prognosis, and guidance for revascularization in patients with CAD.

Comparison of mid- to long-term clinical outcomes between anatomical testing and usual care in patients with suspected coronary artery disease: A meta-analysis of randomized trials

BACKGROUND

Controversies remain regarding clinical outcomes following initial strategies of coronary computed tomography angiography (CCTA) vs usual care with functional testing in patients with suspected coronary artery disease (CAD).

HYPOTHESIS

CCTA as initial diagnostic strategy results in better mid- to long-term outcomes than usual care in patients with suspected CAD.

METHODS

We searched PubMed, Embase, and Cochrane Library for randomized controlled trials comparing clinical outcomes during ≥6 months' follow-up between initial anatomical testing by CCTA vs usual care with functional testing in patients with suspected CAD. Occurrence of all-cause mortality, nonfatal myocardial infarction (MI), and major adverse cardiovascular events (MACE), and use of invasive coronary angiography and coronary revascularization, were compared between the 2 diagnostic strategies.

RESULTS

Twelve trials were included (20 014 patients; mean follow-up, 20.5 months). Patients undergoing CCTA as initial noninvasive testing had lower risk of nonfatal MI compared with those treated with usual care (risk ratio [RR]: 0.70, 95% confidence interval [CI]: 0.52-0.94, P = 0.02). There was a tendency for reduced MACE following initial CCTA strategy, but not for risk of all-cause mortality. Compared with functional testing, the CCTA strategy increased use of invasive coronary angiography (RR: 1.53, 95% CI: 1.12-2.09, P = 0.007) and coronary revascularization (RR: 1.49, 95% CI: 1.11-2.00, P = 0.007).

CONCLUSIONS

Anatomical testing with CCTA as the initial noninvasive diagnostic modality in patients with suspected CAD resulted in lower risk of nonfatal MI than usual care with functional testing, at the expense of more frequent use of invasive procedures.