Rationale and Objectives
Several studies have shown that multislice computed tomography (MSCT) has a high sensitivity and specificity for detecting coronary artery stenoses. The aim of the present study was to investigate whether MSCT can reliably triage patients with suspected coronary artery disease (CAD) to coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or no revascularization.
Materials and Methods
A total of 123 patients with suspected CAD who were referred for conventional coronary angiography (CATH) additionally underwent MSCT (16*0.5 mm detector collimation). Therapeutic decisions made on the basis of CATH and MSCT strictly following current guidelines for treatment of CAD were compared with decisions made by a cardiac surgeon and an interventional cardiologist. Only MSCTs with at least adequate image quality in all coronary segments were included in the analysis (94/123).
Results
Decisions made on the basis of MSCT and CATH according to guidelines did not differ significantly (agreement of 88%, 82 of 94, P = .319). The therapeutic decisions made by the interventional cardiologist and the cardiac surgeon based on CATH differed significantly (overall agreement of 79%, 74 of 94 cases, P < .001; cardiologist: 78% PCI and 22% CABG versus surgeon: 38% PCI and 62% CABG), whereas there was 100% agreement regarding decisions for or against invasive treatment.
Conclusions
MSCT shows good agreement with CATH in triaging patients with suspected CAD to CABG, PCI, or no revascularization. The choice of revascularization procedure is significantly more strongly influenced by whether an interventional cardiologist or a cardiac surgeon makes the decision than by the diagnostic test on which the decision is based.
Coronary artery disease (CAD) is one of the most common diseases in industrialized countries ( ). It is diagnosed noninvasively using resting electrocardiography (ECG), exercise ECG, scintigraphy, echocardiography, and stress echocardiography. These diagnostic tests vary in their sensitivities and specificities ( ). CAD is confirmed or excluded invasively by conventional coronary angiography (CATH), which has a mortality of 0.11% and a complication rate of 1.7% for major adverse cardiac and cerebrovascular events (MACCE) when performed as an elective diagnostic procedure ( ). Multislice computed tomography (MSCT) involves the same radiation exposure and reliably depicts the coronary vessels with a sensitivity and specificity for the detection of hemodynamically significant stenoses of 85% and 95%, respectively. The technical advances made in recent years have continuously improved image analysis ( ). The aim of the present study was to determine how well a therapeutic decision for either coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or no revascularization can be made on the basis of the MSCT findings in comparison with CATH (gold standard). To this end, we compared the therapeutic decisions made on the basis of MSCT and CATH in accordance with current guidelines with the therapeutic decisions made by specialists for PCI (interventional cardiologist) and CABG (cardiac surgeon).
Material and methods
Patients
One hundred and twenty-three (92 men and 31 women, mean age 62.3 ± 8.7 years) with suspected CAD who were referred to our institution by outpatient centers were investigated by elective CATH and MSCT as part of an investigator-initiated study comparing MSCT and magnetic resonance coronary angiography ( ). Inclusion criteria were age at least 40 years and a sinus rhythm. Patients with contraindications to iodinated contrast agents, renal insufficiency, cardiac arrhythmia, coronary artery stents, or bypass grafts were excluded. The study was approved by the institutional review board and all patients gave written informed consent.
MSCT Protocol
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Conventional Coronary Angiography
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Guideline-Based Triage Using a Flow Chart
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Therapeutic Decision-Making by an Interventional Cardiologist and a Cardiac Surgeon
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Statistical Analysis
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Results
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Table 1
Agreement of Therapeutic Decisions Based on MSCT and CATH Made According to the Guidelines for the Treatment of Coronary Artery Disease
MSCT CABG PCI No Revascularization Total CATH CABG 9 1 0 10 PCI 3 27 5 35 No revascularization 0 2 47 49 Total 12 30 52 94
The statistical results were as follows: agreement: 88%; Kappa: 0.798; McNemar’s test: P = .319; agreement for decision between PCI and CABG: 90%; agreement for decision between revascularization and no revascularization: 93%; accuracy for decision for revascularization: 89%; accuracy for decision against revascularization: 96%; predictive value of MSCT for revascularization: 95%.
CABG: coronary artery bypass graft; CATH: conventional coronary angiography; MSCT: multislice computed tomography; PCI: percutaneous coronary intervention.
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Table 2
Agreement Between Interventional Cardiologist and Cardiac Surgeon Based on CATH
Cardiac Surgeon CABG PCI No Revascularization Total Interventional cardiologist CABG 11 0 0 11 PCI 20 19 0 39 No revascularization 0 0 44 44 Total 31 19 44 94
The statistical results were as follows: agreement: 79%; McNemar’s: P < .001 (indicating significant differences between the two physicians); Kappa: 0.677; agreement for decision between PCI and CABG: 60%; and agreement for decision between revascularization and no revascularization: 100%.
CABG: coronary artery bypass graft; CATH: conventional coronary angiography; MSCT: multislice computed tomography; PCI: percutaneous coronary intervention.
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Table 3
Agreement Between Interventional Cardiologist and Cardiac Surgeon Based on MSCT
Cardiac Surgeon CABG PCI No Revascularization Total Interventional cardiologist CABG 6 0 0 6 PCI 21 17 0 38 No revascularization 0 1 49 50 Total 27 18 49 94
The statistical results were as follows: agreement: 77%; McNemar’s test: P < .001 (indicating significant differences between the two physicians); Kappa: 0.672; agreement for decision between PCI and CABG: 52%; and agreement for decision between revascularization and no revascularization: 99%.
CABG: coronary artery bypass graft; CATH: conventional coronary angiography; MSCT: multislice computed tomography; PCI: percutaneous coronary intervention.
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Discussion
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