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Curso de Atualização em Medicina Cardiovascular 2019
Reunião Anual Conjunta dos Grupos de Estudo de Cirurgia Cardíaca, Doenças Valvulares e Ecocardiografia da SPC
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08. Ventricular Arrhythmias and Sudden Cardiac Death (SCD)
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Optimizing diagnosis of obstrutive coronary artery disease by CT angiography and ischemia test. A randomized clinical trial
Session:
CO3 - Doença Coronária
Speaker:
João Pedro Dias Ferreira Reis
Congress:
CPC 2019
Topic:
E. Coronary Artery Disease, Acute Coronary Syndromes, Acute Cardiac Care
Theme:
12. Coronary Artery Disease (Chronic)
Subtheme:
12.3 Coronary Artery Disease – Diagnostic Methods
Session Type:
Comunicações Orais
FP Number:
---
Authors:
João Pedro Reis; Ruben Ramos; Pedro Modas Daniel; Sílvia Aguiar Rosa; Luís Almeida Morais; Madalena Coutinho Cruz; Rita Ilhão Moreira; Tiago Mendonça; André Viveiros Monteiro; Cecília Leal; Hugo Marques; Luísa Figueiredo; Rui Cruz Ferreira
Abstract
<p><strong>Aim</strong> In patients with suspected coronary artery disease (CAD), computed tomographic angiography (CTA) may improve patient selection for invasive coronary angiography (ICA) as alternative to functional testing. However, the role of CTA in symptomatic patients after abnormal functional test is incompletely defined.</p> <p><strong>Methods and results</strong> This randomized clinical trial conducted in single academic tertiary center selected 218 symptomatic patients (pts) with mild to moderately abnormal functional test referred to invasive coronary to receive either the originally intended ICA (n = 103) or CTA (n = 115). CTA interpretation and subsequent care decisions were made by the clinical team. Patients with high risk features on functional tests, previous acute coronary syndrome, previously documented CAD, chronic kidney disease (GFR<60ml/min/1.73m<sup>2</sup>) or persistent atrial fibrillation were excluded. The primary endpoint was the percentage of ICA with no significant obstructive CAD (no stenosis ≥50%) in each group. Diagnostic and revascularization yields of ICA in either group were also assessed. Subjects averaged 68 ±9 years of age, 60% were male, 29% were diabetic. Nuclear perfusion stress test was used in 33.9% in CTA group and 31.1% in control group (p=0.655). Mean post (functional) test probability of obstructive CAD was 34%. Overall prevalence of obstructive CAD was 32.1%. In the CTA group, ICA angiography was cancelled by referring physicians in 83 of the pts (72.2%) after receiving CTA results. For those undergoing ICA, non-obstructive CAD was found in 5 pts (15.6%) in the CTA-guided arm and 60 (58.3%) in the usual care arm (P<0.001). Mean cumulative radiation exposure related to diagnostic work up was similar in both groups (6±14 vs 5±14mSv, P=0.152), but a greater cumulative contrast dose in the CTA-guided group (87.5±21 vs 77±40, p=0.026) was observed. Both diagnostic (84.4% vs 41.7, p<0.001) and revascularization (71.9% vs 38.8%, p=0.001) yields were significantly higher for CTA-guided ICA as compared to standard functional test-guided ICA. </p> <p><strong>Conclusions </strong>In patients with suspected CAD and mild to moderately abnormal functional test, a diagnostic strategy including computed tomographic angiography as gatekeeper is effective and significantly improves diagnostic and revascularization yields of invasive coronary angiography.</p>
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