Selective referrals of coronary CTA were determined to be a more efficient and accurate method in guiding decisions of invasive coronary angiography for suspected CAD vs. a direct referral strategy, according to findings published in JACC: Cardiovascular Imaging.
Researchers sought to compare the safety and diagnostic yield using coronary CTA compared with a direct referral strategy using invasive coronary angiography (ICA) as the index procedure.
“Although current professional guidance documents offer direction for appropriate selection of patients for elective ICA, previous studies observed that most individuals who underwent nonemergent ICA did not have actionable CAD,” Hyuk-Jae Chang, MD, PhD, of the division of cardiology at Severance Cardiovascular Hospital at Yonsei University Health System in Seoul, South Korea, and colleagues wrote.
The multinational, randomized CONSERVE clinical trial consisted of patients (mean age, 60 years; 46% women) referred to ICA for nonemergent indications and were assigned a selective referral strategy (n = 823) or a direct referral strategy (n = 808).
CAD risk factors were also prevalent (58% with hypertension, 34% with dyslipidemia, 28% with diabetes and 30% current or former smokers), researchers wrote.
The primary endpoint was noninferiority with a multiple margin of 1.33 of composite major adverse CV events at a median follow-up of 12 months (interquartile range, 11.7-13.2).
During follow-up, 4.6% of the selective referral group and 4.6% of the direct referral group experienced major adverse CV events (HR = 0.99; 95% CI, 0.66-1.47).
After coronary CTA, researchers identified that 23% of the selective referral patients went on to ICA compared with 100% of the direct referral group. Researchers wrote that coronary revascularization occurred less often in the selective referral group compared with the direct referral group (13% vs. 18%; P < .001), and rates of normal ICA were 24.6% in the selective referral arm compared with 61.1% in the direct referral group (P < .001).
Growing evidence supports that noninvasive anatomic testing by coronary CTA alone, as a gatekeeper procedure, may prove advantageous for promptly and accurately identifying candidates for downstream procedures, according to the researchers.
“In this trial of stable patients with suspected CAD who were referred for guideline-directed ICA, a selective referral strategy was found in similar [major adverse CV event] rates at 1 year of follow-up compared with a direct referral strategy,” Chang and colleagues wrote. “These data and similarly relevant findings from other randomized trials call for revisions to the current ischemic heart disease guidelines for the evaluation of patients with stable ischemic heart disease.” – by Earl Holland Jr.
Disclosures: Chang reports receiving a research grant from the Leading Foreign Research Institute Recruitment Program through the National Research Foundation of Korea, Ministry of Science, ICT & Future Planning. Please see the study for all other authors’ relevant financial disclosures.