CT Angiography Scans Avoid Catheter Angiograms, Saves Money in Suspected Coronary Artery Disease

CT Angiography Avoids Caths, Saves Money in Suspected CAD

Patrice Wendling

September 02, 2016




Debate: Strong Case for Performing CT First in Suspected, Low-Risk CAD
DeFACTO Result: CCTA, Standard Angiography Similarly Prognostic

ROME, ITALY — Outcomes are similar and pocketbooks spared if computed-tomography angiography (CTA) is used to guide the use of invasive coronary angiography in stable patients with suspected CAD, according to the Coronary Computed Tomographic Angiography for Selective Cardiac Catheterization(CONSERVE) study[1].

The 12-month major adverse cardiovascular event (MACE) rate was identical (4.6%) in patients evaluated with selective or direct invasive coronary angiography (P=0.99).

The CTA-guided strategy, however, reduced rates of invasive coronary angiography by 78% (22% vs 100%), revascularization by 41% (10% vs 17%), and cardiovascular costs by 50% (mean per patient $3338 vs $6740; P for all <0.001).

Dr Hyuk-Jae Chang

In light of the 4.6 million catherizations performed each year, the cost saving with the selective CTA strategy could be substantial, co–principal investigator Dr Hyuk-Jae Chang (Yonsie University College of Medicine, Seoul, South Korea) suggested at the European Society of Cardiology (ESC) Congress 2016.

American College of Cardiology (ACC) vice president Dr C Michael Valentine (Central Health, Lynchburg, VA) told heartwire from Medscape, however, that outside of Medicare, many US payers currently do not reimburse for CTA.

Also, the study lacked information on how many patients met appropriate-use criteria for CTA and how other noninvasive testing strategies would compare, as was done in year’s PROMISE trial.

“You would expect the cost to be lower, you would expect the interventional procedures to be lower, and you’d expect overall, probably a better safety profile in all those who undergo noninvasive testing in this situation first, so I’m not sure this taught us anything new,” Valentine said.

CONSERVE randomized 1503 stable patients with an ACC/American Heart Association (AHA) class II indication for nonemergent angiography to direct or selective angiography, the latter driven by physician referrals based on the initial results of the CT.

There were no between-group differences in angina typicality, pretest likelihood of obstructive CAD, symptoms, ACC/AHA guideline indication for referral to invasive coronary angiography, rates of obstructive CAD, number of vessels, and location of CAD, Chang said.

Discussant Dr Stephan Achenbach (University Hospital Erlangen, Germany) said the findings fit nicely with other recent evidence and that this is “one of the rare randomized diagnostic imaging trials with an outcome end point.”

The study, however, did have limitations, mainly that this was a very low-risk cohort, which was reflected by the extremely low MACE rate.

“So we also have to ask the question, what would be the effect of doing no testing at all in these patients, which has not been studied.”

The study was funded by an investigator-initiated unrestricted grant from GE Healthcare and Severance Hospital of Yonsei University. The investigators reported no relevant financial relationships. 

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