Rationale and Objectives
To determine the impact of coronary computed tomography angiography (CCTA) on treatment decisions made by cardiac surgeons and to explore barriers to implementation of CCTA as first-line imaging workup before coronary artery bypass.
Materials and Methods
Tertiary academic medical center retrospective cohort study. Questionnaires administered to three cardiac surgeons regarding diagnosis and treatment decisions with level of confidence in decision making for 30 chest pain patients, after reviewing deidentified catheter coronary angiogram (CCA) and CCTA images on the same patients, several weeks apart.
Results
All surgeons tended to report more severe disease with CCTA than CCA ( P < .05). Treatment decisions differed in 12 (40%), 14 (47%), and 18 (60%) patients within each individual surgeon based on CCTA images compared to CCA images ( P = .11, .01, and .02, respectively). Confidence levels were significantly higher with CCA for the diagnosis and treatment of coronary artery disease for all three surgeons ( P < .05). There was a tendency toward more invasive treatment choices (angioplasty, stent insertion, or coronary artery bypass graft) when making treatment decisions based upon CCTA images.
Conclusions
Severity of disease may be overestimated by cardiac surgeons when using CCTA as a decision-making test, tending toward more invasive treatment choices compared to CCA. Additionally, cardiac surgeons may be more confident with their diagnosis and treatment based on CCA. These may be important limitations in the application of CCTA in clinical practice and may reflect the maturation of CCTA use in practice, diffusion of the technology and/or a reflection of the technology itself.
Coronary artery disease (CAD) is a major cause of mortality in the United States, responsible for approximately 1 in 6 deaths . In 2009, there were 1,476,000 inpatient diagnostic cardiac catheterizations performed, and less than half of these (693,000) were associated with a percutaneous coronary intervention . In 2008, there were almost a quarter of a million coronary artery bypass grafts (CABG) performed (1081 per million adults) in the United States with the annual numbers decreasing, estimated at about 150,000 CABG performed in 2012 . Patients being evaluated for CABG require imaging of the coronary arteries to evaluate the vessels that require bypass and potential targets for distal anastomosis.
Coronary computed tomography angiography (CCTA) is a relatively new noninvasive diagnostic test for CAD, which requires peripheral intravenous iodinated contrast injection and permits omniplanar imaging best suited to the position and angulation of each individual coronary artery segment. CCTA is a highly sensitive test with good specificity and a very high negative predictive value, most useful for patients at low or intermediate risk for CAD . Recent technological advancements allow faster imaging at higher heart rates with less radiation exposure . Catheter coronary angiography (CCA) is the reference standard for diagnosing CAD. It is invasive, requiring direct injection of contrast material into the coronary arteries, has a higher complication rate than CCTA, and is significantly more expensive, but permits concomitant intervention for coronary artery stenosis if appropriate . The costs billed for and payments received by the hospital for a CCA are about two to three times greater than for CCTA . CCTA could potentially replace CCA in patients who are at lower risk for CAD and have a lower probability of requiring subsequent intervention.
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Methods
Setting
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Patient Selection
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Data Collection
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Questionnaire
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Study Outcomes
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CCTA
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Catheter Angiography
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Statistical Analysis
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Results
Patient Demographics and Clinical Symptoms
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Table 1
Patient Profile: Symptoms and Treatment
Category Number (%) of Patients Total number of patients 30 Confirmed coronary artery disease 24 (80) Significant 13 (43) Nonsignificant 11 (36) Reason for referral Historical finding Hypertension 13 (43) Hyperlipidemia 17 (56) Diabetes mellitus 7 (21) Percutaneous coronary intervention: stent 4 (12) Percutaneous coronary intervention: angioplasty 2 (6) Coronary artery bypass grafting 1 (3) Positive findings on other tests 15 (50) Current symptoms None 4 (12) Chest pain 23 (69) Shortness of breath 4 (12) Atypical or noncardiac chest pain 3 (9) Fatigue 5 (15) Palpitations 3 (9) Treatment history Medical therapy 14 (46) Percutaneous coronary intervention: stent 5 (15) Percutaneous coronary intervention: angioplasty 2 (6) Bypass grafting 2 (6) Valve surgery 2 (6)
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Diagnostic Performance of CCTA versus CCA
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Table 2
Cardiac Surgeon Recording of Coronary Artery Disease Severity for Catheter Coronary Angiography and Coronary Computed Tomography Angiography
(%) Catheter Coronary Angiography Coronary Computed Tomography Angiography ∗ P Value Agreement between Modalities Reader 1 Number (percentage) Number (percentage) .03 Number (percentage) Normal 7 (23) 2 (7) 1 (3) Mild 10 (33) 9 (30%) 3 (11) Significant 13 (44) 19 (63) 10 (33) Reader 2 Number (percentage) Number (percentage) .05 Normal 7 (23) 4 (13) 2 (7) Mild 11 (37) 9 (30) 4 (13) Significant 12 (40) 17 (57) 11 (37) Reader 3 Number (percentage) Number (percentage) .03 Normal 5 (17) 3 (10) 1 (3) Mild 10 (33) 5 (17) 3 (10) Significant 15 (50) 22 (73) 13 (44)
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Choices of Treatment Based on CCA Report versus CCTA Report
Overall
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Table 3
Choice of Treatment Plan Based on Catheter Coronary Angiography and Coronary CT Angiography Interpretations
(%) Catheter Coronary Angiography Coronary CT Angiography_P_ Value ∗ Agreement between Modalities Reader 1 Number (percentage) Number (percentage) .11 Number (percentage) No treatment 2 (7) 1 (4) 0 (0) Medical therapy 18 (60) 17 (52) 11 (40) Percutaneous coronary intervention 8 (26) 3 (11%) 1 (3) Coronary artery bypass graft 2 (7) 9 (33) 0 (0) Other treatments 0 (0%) 0 (0) 0 (0)Total intervention/surgery 10 (33) 11 (40) .52 1 (3) Reader 2 Number (percentage) Number (percentage) .01 No treatment 6 (20) † 6 (20) 4 (14) Medical therapy 13 (43) 1 (3) 0 (0) Percutaneous coronary intervention 7 (23) † 16 (53) 7 (23) Coronary artery bypass graft 4 (14) 5 (17) 3 (11) Other treatment 0 (0) 2 (7) 0 (0Total intervention/surgery 11 (37) 21 (70) .004 10 (33%) Reader 3 Number (percentage) Number (percentage) .02 No treatment 1 (3) 1 (3) 0 (0) Medical therapy 15 ‡ (50) 8 ‡ (27) 6 (20) Percutaneous coronary intervention 6 (20) 10 (33) 4 (14) Coronary artery bypass graft 8 (27) 11 (37) 7 (23) Other treatment 0 (0) 0 (0) 0 (0)Total intervention/surgery 14 (47) 21 (70) .008 11 (40)
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Surgical versus nonsurgical treatment
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Confidence in Surgical Decision-Making
Level of confidence in the diagnosis of CAD
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Table 4
Diagnostic Confidence of Cardiac Surgeons for the Diagnosis of and Treatment Planning for Coronary Artery Disease, Mean (95% CI)
A. Coronary Artery Disease Diagnosis Catheter Coronary Angiography Coronary CT Angiography ∗ P Value Reader 1 9.6 (9.3–9.8) 7.4 (6.6–8.1) <.001 Reader 2 10 9.6 (9.3–9.9) .008 Reader 3 7.8 (7.3–8.3) 7.06 (6.5–7.6) .02
B. Treatment Planning Mean Catheter Coronary Angiography Coronary CT Angiography_P_ Value Reader 1 9.2 (8.8–9.6) 7.1 (6.4–7.8) <.001 Reader 2 10 9.8 (9.5–10) .02 Reader 3 7.1 (6.5–7.6) 6.6 (5.8–7.4) .37
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Level of confidence in selection of treatment
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Reader Variability
Diagnosis and treatment of CAD
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Confidence for diagnosis and treatment of CAD
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Discussion
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Limitations
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Implications
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AcknowledgmentS
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Surgical decision-making questionnaire Patient number______
Question 1
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Please fill in the table below with respect to presence of disease and disease severity (not visualized, normal, less than 70% stenosis, 70% or more stenosis)
Reader Name: Modality (Circle One) CCA CTA Date: Stenosis Coronary Segment Number and Name Nonvisualized None <70% ≥70% 1 Proximal right coronary artery 2 Mid right coronary artery 3 Distal right coronary artery 4 Right posterior descending artery 5 Right posterior atrioventricular segment 11 Left main coronary artery 12 Proximal left anterior descending artery 13 Mid left anterior descending artery 14 Distal left anterior descending artery 15 First diagonal branch 16 Second diagonal branch 18 Proximal circumflex artery 19 Mid circumflex artery 19a Distal circumflex artery 20 First obtuse marginal 21 Second obtuse marginal 22 Third obtuse marginal branch segment 23 Circumflex artery atrioventricular groove continuation 24 First left posterolateral branch 28 Ramus intermedius
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Question 2
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Question 3
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Question 4
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