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On the Inappropriateness of Noninvasive Multidetector Computed Tomography Coronary Angiography to Trigger Coronary Revascularization

A Comparison With Invasive Angiography

Giovanna Sarno, MD, PhD^_*, Isabel Decraemer, BSc, Piet K. Vanhoenacker, MD, PhD, Bernard De Bruyne, MD, PhD^_*, Michalis Hamilos, MD, PhD^_*, Thomas Cuisset, MD^_*, Eric Wyffels, MD^_*, Jozef Bartunek, MD, PhD^_*, Guy R. Heyndrickx, MD, PhD^_*, William Wijns, MD, PhD^_*,_*

^_* Cardiovascular Center, OLV Hospital, Aalst, Belgium
Department of Radiology, OLV Hospital, Aalst, Belgium

^_* Reprint requests and correspondence: Dr. William Wijns, Cardiovascular Center Aalst, OLV Ziekenhuis, Moorselbaan 164, 9300 Aalst, Belgium (Email: William.Wijns{at}olvz-aalst.be).

Objectives: Our purpose was to evaluate the appropriateness of multidetector computed tomography angiography (MDCTA) as an anatomical standard for decision making in patients with known or suspected coronary artery disease.

Background: Although correlative studies between MDCTA and coronary angiography (CA) show good agreement, MDCTA visualizes plaque burden and calcifications well before luminal dimensions are encroached.

Methods: Pressure-derived fractional flow reserve (FFR) was obtained in 81 patients (116 vessels) who underwent both CA and MDCTA. Segments were visually graded for stenosis severity as: G0 = normal, G1 = nonobstructive (<50% diameter reduction), and G2 = obstructive (50% diameter reduction).

Results: Concordance between segmental severity scores by MDCTA and CA was good (k = 0.74; 95% confidence interval: 0.56 to 0.92). Diagnostic performance of MDCTA for detection of functionally significant stenosis based on FFR was low (sensitivity 79%; specificity 64%; positive likelihood ratio 2.2; negative likelihood ratio 0.3). Revascularization was considered appropriate in the presence of reduced FFR (0.75). Decision making based on MDCTA guidance would result in revascularization in the absence of ischemia in 22% of patients (18 of 81) and inappropriate deferral in 7% (6 of 81), while revascularization in the absence of ischemia would be 16% (13 of 81) and inappropriate deferral 12% (10 of 81) with decisions guided by CA. Combined evaluation of stenosis severity using both anatomy (with either CA or MDCTA) and function (with FFR) yields the highest proportion of appropriate decisions: 90% and 91%, respectively (p = 0.0001 vs. CA only, p = 0.0001 vs. MDCTA only).

Conclusions: Similar to CA, anatomical assessment of coronary stenosis severity by MDCTA does not reliably predict its functional significance.

Key Words: computed tomography • coronary disease • revascularization

Abbreviations and Acronyms   CA = coronary angiography   CAD = coronary artery disease   FFR = fractional flow reserve   LAD = left anterior descending coronary artery   MDCTA = multidetector computed tomography angiography   PCI = percutaneous coronary intervention

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