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Consequence of Overuse of Invasive Coronary Angiography

Consequence of Overuse of Invasive Coronary Angiography We agree with Becker et al1 that the outcome of coronary artery dissection was the result of overuse of diagnostic imaging. However, it was not the result of the CCTA examination but rather the response to that result that likely was in error. Unnecessary invasive coronary angiography (ICA) examinations are performed routinely in patients. A recent publication showed that no CAD was found in 39.6% of patients and obstructive CAD was found in only 37.6% of patients.2 In many patients, ICA can result in added unnecessary cost and a small but significant morbidity and mortality. The results of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial suggest that patients with stable angina diagnosed as having CAD and initially treated with optimal medical therapy (OMT) alone have no difference in outcomes compared with individuals treated with both OMT and percutaneous coronary intervention.3 The patient described in the report by Becker et al1 had atypical chest pain and CAD diagnosed by CCTA. Rather than performing ICA as the next step, a more conservative approach would be to simply treat the patient medically, and if the patient's symptoms failed to stabilize, consider performing ICA with the idea of revascularization if a significant stenosis was confirmed. Such a conservative approach is entirely in keeping with the knowledge that has been gained from the COURAGE trial. No significant stenosis was noted on ICA for this patient, so the CCTA would be normally considered to be a false-positive result. However, it is possible that the patient's symptoms were due to microvascular disease for which OMT would still be considered to be appropriate treatment.4 When considering patients with microvascular disease, ICA may be a poor reference standard for CCTA. While the COURAGE trial suggests OMT in patients with stable angina, the RESCUE (Randomized Evaluation of Patients with Stable Angina Comparing Utilization of Diagnostic Examinations) trial (clinicaltrials.gov NCT01262625) seeks to assess outcomes of patients with symptoms of stable angina undergoing CCTA who demonstrate CAD treated with an initial trial of OMT. We believe, as findings from the COURAGE trial suggest, that patients with CAD treated with OMT will have no poorer outcomes and may, in instances such as the patient in the report by Becker et al,1 do better than patients who undergo ICA. While waiting for the results from this trial, we suggest following published appropriateness criteria5 and taking a more conservative approach. Correspondence: Dr Stillman, Department of Radiology, Emory University, 1365 Clifton Rd NE, Atlanta, GA 30322 (aestill@emory.edu). Financial Disclosure: None reported. RESCUE Investigators: Mehdi Adineh, PhD, William Black, PhD, Illana Gareen, PhD, Constantine Gatsonis, PhD, Udo Hoffmann, MD, MPH, Joao Lima, MD, Kreton Mavromatis, MD, Mitchell Schnall, MD, PhD, Arthur E. Stillman, MD, PhD, James Udelson, MD, Pamela K. Woodard, MD. This article was corrected for a typographical error on April 11, 2011. References 1. Becker MCGalla JMNissen SE Left main trunk coronary artery dissection as a consequence of inaccurate coronary computed tomographic angiography [published online December 13, 2010]. Arch Intern Med 2011;171 (7) 698- 701Google ScholarCrossref 2. Patel MRPeterson EDDai D et al. Low diagnostic yield of elective coronary angiography. N Engl J Med 2010;362 (10) 886- 895PubMedGoogle ScholarCrossref 3. Boden WEO’Rourke RATeo KK et al. COURAGE Trial Research Group, Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007;356 (15) 1503- 1516PubMedGoogle ScholarCrossref 4. Bairey Merz CNShaw LJReis SE et al. WISE Investigators, Insights from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study, part II: gender differences in presentation, diagnosis, and outcome with regard to gender-based pathophysiology of atherosclerosis and macrovascular and microvascular coronary disease. J Am Coll Cardiol 2006;47 (3) ((Suppl)) S21- S29PubMedGoogle ScholarCrossref 5. Taylor AJCerqueira MHodgson JM et al. ACCF/SCCT/ACR/AHA/ASE /ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol 2010;56 (22) 1864- 1894PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Consequence of Overuse of Invasive Coronary Angiography

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Publisher
American Medical Association
Copyright
Copyright © 2011 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinternmed.2011.112
Publisher site
See Article on Publisher Site

Abstract

We agree with Becker et al1 that the outcome of coronary artery dissection was the result of overuse of diagnostic imaging. However, it was not the result of the CCTA examination but rather the response to that result that likely was in error. Unnecessary invasive coronary angiography (ICA) examinations are performed routinely in patients. A recent publication showed that no CAD was found in 39.6% of patients and obstructive CAD was found in only 37.6% of patients.2 In many patients, ICA can result in added unnecessary cost and a small but significant morbidity and mortality. The results of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial suggest that patients with stable angina diagnosed as having CAD and initially treated with optimal medical therapy (OMT) alone have no difference in outcomes compared with individuals treated with both OMT and percutaneous coronary intervention.3 The patient described in the report by Becker et al1 had atypical chest pain and CAD diagnosed by CCTA. Rather than performing ICA as the next step, a more conservative approach would be to simply treat the patient medically, and if the patient's symptoms failed to stabilize, consider performing ICA with the idea of revascularization if a significant stenosis was confirmed. Such a conservative approach is entirely in keeping with the knowledge that has been gained from the COURAGE trial. No significant stenosis was noted on ICA for this patient, so the CCTA would be normally considered to be a false-positive result. However, it is possible that the patient's symptoms were due to microvascular disease for which OMT would still be considered to be appropriate treatment.4 When considering patients with microvascular disease, ICA may be a poor reference standard for CCTA. While the COURAGE trial suggests OMT in patients with stable angina, the RESCUE (Randomized Evaluation of Patients with Stable Angina Comparing Utilization of Diagnostic Examinations) trial (clinicaltrials.gov NCT01262625) seeks to assess outcomes of patients with symptoms of stable angina undergoing CCTA who demonstrate CAD treated with an initial trial of OMT. We believe, as findings from the COURAGE trial suggest, that patients with CAD treated with OMT will have no poorer outcomes and may, in instances such as the patient in the report by Becker et al,1 do better than patients who undergo ICA. While waiting for the results from this trial, we suggest following published appropriateness criteria5 and taking a more conservative approach. Correspondence: Dr Stillman, Department of Radiology, Emory University, 1365 Clifton Rd NE, Atlanta, GA 30322 (aestill@emory.edu). Financial Disclosure: None reported. RESCUE Investigators: Mehdi Adineh, PhD, William Black, PhD, Illana Gareen, PhD, Constantine Gatsonis, PhD, Udo Hoffmann, MD, MPH, Joao Lima, MD, Kreton Mavromatis, MD, Mitchell Schnall, MD, PhD, Arthur E. Stillman, MD, PhD, James Udelson, MD, Pamela K. Woodard, MD. This article was corrected for a typographical error on April 11, 2011. References 1. Becker MCGalla JMNissen SE Left main trunk coronary artery dissection as a consequence of inaccurate coronary computed tomographic angiography [published online December 13, 2010]. Arch Intern Med 2011;171 (7) 698- 701Google ScholarCrossref 2. Patel MRPeterson EDDai D et al. Low diagnostic yield of elective coronary angiography. N Engl J Med 2010;362 (10) 886- 895PubMedGoogle ScholarCrossref 3. Boden WEO’Rourke RATeo KK et al. COURAGE Trial Research Group, Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007;356 (15) 1503- 1516PubMedGoogle ScholarCrossref 4. Bairey Merz CNShaw LJReis SE et al. WISE Investigators, Insights from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study, part II: gender differences in presentation, diagnosis, and outcome with regard to gender-based pathophysiology of atherosclerosis and macrovascular and microvascular coronary disease. J Am Coll Cardiol 2006;47 (3) ((Suppl)) S21- S29PubMedGoogle ScholarCrossref 5. Taylor AJCerqueira MHodgson JM et al. ACCF/SCCT/ACR/AHA/ASE /ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol 2010;56 (22) 1864- 1894PubMedGoogle ScholarCrossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Apr 11, 2011

Keywords: coronary angiography

References

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