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Zhou J, Li C, Cong H, Duan L, Wang H, Wang C, Tan Y, Liu Y, Zhang Y, Zhou X, Zhang H, Wang X, Ma Y, Yang J, Chen Y, Guo Z. Comparison of Different Investigation Strategies to Defer Cardiac Testing in Patients With Stable Chest Pain. JACC Cardiovasc Imaging 2021; 15:91-104. [PMID: 34656487 DOI: 10.1016/j.jcmg.2021.08.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 08/30/2021] [Accepted: 08/31/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVES This study aimed to compare the current 5 investigation strategies to defer cardiac testing in patients with stable chest pain. BACKGROUND For the clinical management of stable chest pain, the identification of patients unlikely to benefit from further cardiac testing is important, but the most appropriate investigation strategy is unknown. METHODS A total of 4,207 patients referred to coronary computed tomography angiography for stable chest pain were classified into low- and high-risk groups according to the 2016 National Institute of Health and Care Excellence (NICE) guideline-determined strategy; PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) minimal risk tool-based strategy; 2019 European Society of Cardiology (ESC) guideline-determined strategy; and coronary artery calcium score (CACS), either in isolation (the CACS strategy) or as part of a weighted clinical likelihood model-based strategy (the CACS-CL strategy). The associations of obstructive coronary artery disease on coronary computed tomography angiography, major adverse cardiovascular events, and subsequent clinical management with risk groups according to different strategies were evaluated and compared. RESULTS The NICE, PROMISE, ESC, CACS, and CACS-CL strategies classified a proportion (22.63%, 29.21%, 41.84%, 46.76%, and 51.41%, respectively) of patients into low-risk groups. Compared with the NICE, PROMISE, ESC, and CACS strategies, the CACS-CL strategy had a stronger association between risk groups and obstructive coronary artery disease (odd ratios: 16.00 vs 2.93, 5.53, 7.94, and 10.39, respectively), major adverse cardiovascular events (HRs: 6.83 vs 1.90, 2.94, 4.23, and 5.13, respectively) and intensive subsequent clinical management as well as better metrics of diagnostic accuracy and positive net reclassification improvement. CONCLUSIONS Among contemporary strategies used to identify patients with stable chest pain at low risk, the use of CACS, especially when combined with clinical risk features, showed the strongest potential to effectively defer cardiac testing.
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Affiliation(s)
- Jia Zhou
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China.
| | - Chunjie Li
- Department of Emergency, Tianjin Chest Hospital, Tianjin, China
| | - Hongliang Cong
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Lixiong Duan
- Graduate School of Tianjin Medical University, Tianjin, China
| | - Hao Wang
- National Center for Clinical Medical Research of Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Chengjian Wang
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Yahang Tan
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yujie Liu
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Ying Zhang
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Xiujun Zhou
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Hong Zhang
- Department of Radiology, Tianjin Chest Hospital, Tianjin, China
| | - Xing Wang
- Department of Radiology, Tianjin Chest Hospital, Tianjin, China
| | - Yanhe Ma
- Department of Radiology, Tianjin Chest Hospital, Tianjin, China
| | - Junjie Yang
- Department of Cardiology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yundai Chen
- Department of Cardiology, Chinese People's Liberation Army General Hospital, Beijing, China.
| | - Zhigang Guo
- Department of Cardiovascular Surgery, Tianjin Chest Hospital, Tianjin, China.
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Shaw LJ, Hachamovitch R, Min JK, Di Carli M, Mieres JH, Phillips L, Blankstein R, Einstein A, Taqueti VR, Hendel R, Berman DS. Evolving, innovating, and revolutionary changes in cardiovascular imaging: We've only just begun! J Nucl Cardiol 2018; 25:758-768. [PMID: 29468466 DOI: 10.1007/s12350-018-1225-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 01/09/2018] [Indexed: 12/19/2022]
Abstract
In this review, we highlight the need for innovation and creativity to reinvent the field of nuclear cardiology. Revolutionary ideas brought forth today are needed to create greater value in patient care and highlight the need for more contemporary evidence supporting the use of nuclear cardiology practices. We put forth discussions on the need for disruptive innovation in imaging-guided care that places the imager as a central force in care coordination. Value-based nuclear cardiology is defined as care that is both efficient and effective. Novel testing strategies that defer testing in lower risk patients are examples of the kind of innovation needed in today's healthcare environment. A major focus of current research is the evolution of the importance of ischemia and the prognostic significance of non-obstructive atherosclerotic plaque and coronary microvascular dysfunction. Embracing novel paradigms, such as this, can aid in the development of optimal strategies for coronary disease management. We hope that our article will spurn the field toward greater innovation and focus on transformative imaging leading the way for new generations of novel cardiovascular care.
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Affiliation(s)
- Leslee J Shaw
- Emory University School of Medicine, Atlanta, GA, USA.
- Emory University Clinical Cardiovascular Research Institute, 1462 Clifton Rd NE, Room 529, Atlanta, GA, 30324, USA.
| | | | - James K Min
- Weill Cornell Medical College, New York, NY, USA
| | - Marcelo Di Carli
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Ron Blankstein
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Viviany R Taqueti
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert Hendel
- Tulane University School of Medicine, New Orleans, LA, USA
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Leipsic J, Weir-McCall J, Blanke P. FFR CT for Complex Coronary Artery Disease Treatment Planning: New Opportunities. Interv Cardiol 2018; 13:126-128. [PMID: 30443268 DOI: 10.15420/icr.2018.14.3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Coronary computed tomography (CT) is well established for the assessment of symptomatic patients with suspected but not yet confirmed coronary artery disease with high diagnostic accuracy and risk prediction. Until recently, coronary computed tomography angiography (CTA) has played a limited role in the management of complex coronary artery disease (CAD) and in planning revascularisation strategies. With the advent of FFRCT, enabling anatomy and physiology with a single study and the ability to adjudicate lesion specific pressure loss, the potential of combined coronary CT angiography (CCTA) and fractional flow reserve (FFR) computed from non-invasive CT angiography (FFRCT) to inform treatment decision-making and help guide revascularisation has been recognised. In this review, we highlight the evolving role of FFRCT in the management of complex CAD; the opportunities, the data and the unanswered questions.
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Affiliation(s)
- Jonathon Leipsic
- St Paul's Hospital & University of British Columbia, Vancouver, British Columbia Vancouver, Canada
| | - Jonathan Weir-McCall
- St Paul's Hospital & University of British Columbia, Vancouver, British Columbia Vancouver, Canada
| | - Philipp Blanke
- St Paul's Hospital & University of British Columbia, Vancouver, British Columbia Vancouver, Canada
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