Cost-effectiveness of follow-up of pulmonary nodules incidentally detected on cardiac computed tomographic angiography in patients with suspected coronary artery disease.
ABSTRACT: Pulmonary nodules (PNs) are often detected incidentally during coronary computed tomographic (CT) angiography, which is increasingly being used to evaluate patients with chest pain symptoms. However, the efficiency of following up on incidentally detected PN is unknown.We determined demographic and clinical characteristics of stable symptomatic patients referred for coronary CT angiography in whom incidentally detected PNs warranted follow-up. A validated lung cancer simulation model was populated with data from these patients, and clinical and economic consequences of follow-up per Fleischner guidelines versus no follow-up were simulated. Of the 3665 patients referred for coronary CT angiography, 591 (16%) had PNs requiring follow-up. The mean age of patients with PNs was 59±10 years; 66% were male; 67% had ever smoked; and 21% had obstructive coronary artery disease. The projected overall lung cancer incidence was 5.8% in these patients, but the majority died of coronary artery disease (38%) and other causes (57%). Follow-up of PNs was associated with a 4.6% relative reduction in cumulative lung cancer mortality (absolute mortality: follow-up, 4.33% versus non-follow-up, 4.54%), more downstream testing (follow-up, 2.34 CTs per patient versus non-follow-up, 1.01 CTs per patient), and an average increase in quality-adjusted life of 7 days. Costs per quality-adjusted life-year gained were $154 700 to follow up the entire cohort and $129 800 per quality-adjusted life-year when only smokers were included.Follow-up of PNs incidentally detected in patients undergoing coronary CT angiography for chest pain evaluation is associated with a small reduction in lung cancer mortality. However, significant downstream testing contributes to limited efficiency, as demonstrated by a high cost per quality-adjusted life-year, especially in nonsmokers.
Project description:PurposeIn this methodology paper we describe the development of a lung nodule management algorithm specifically for patients undergoing cardiac CT.MethodsWe modified the Lung-RADS algorithm specifically to manage lung nodules incidentally detected on cardiac CT (Lung-RADS for cardiac CT). We will evaluate the modified algorithm as part of the DISCHARGE trial (www.dischargetrial.eu) in which patients with suspected coronary artery disease are randomly assigned to cardiac CT or invasive coronary angiography across Europe at 16 sites involving 3546 patients. Patients will be followed for up to four years.ResultsThe major adjustments to Lung-RADS specifically for cardiac CT relate to 1) incomplete coverage of the lungs by cardiac CT compared with chest CT, and when to order a completion chest CT versus a follow up chest CT, 2) cardiac CT findings will not trigger annual lung-cancer screening, and 3) a lower threshold of at least 10?mm for classifying new ground glass nodules as probably benign (category 3).ConclusionsThe DISCHARGE trial will assess a lung nodule management algorithm designed specifically for cardiac CT in patients with stable chest pain across Europe.
Project description:OBJECTIVE: To evaluate whether invasive coronary angiography or computed tomography (CT) should be performed in patients clinically referred for coronary angiography with an intermediate probability of coronary artery disease. DESIGN: Prospective randomised single centre trial. SETTING: University hospital in Germany. PARTICIPANTS: 340 patients with suspected coronary artery disease and a clinical indication for coronary angiography on the basis of atypical angina or chest pain. INTERVENTIONS: 168 patients were randomised to CT and 172 to coronary angiography. After randomisation one patient declined CT and 10 patients declined coronary angiography, leaving 167 patients (88 women) and 162 patients (78 women) for analysis. Allocation could not be blinded, but blinded independent investigators assessed outcomes. MAIN OUTCOME MEASURE: The primary outcome measure was major procedural complications within 48 hours of the last procedure related to CT or angiography. RESULTS: Cardiac CT reduced the need for coronary angiography from 100% to 14% (95% confidence interval 9% to 20%, P<0.001) and was associated with a significantly greater diagnostic yield from coronary angiography: 75% (53% to 90%) v 15% (10% to 22%), P<0.001. Major procedural complications were uncommon (0.3%) and similar across groups. Minor procedural complications were less common in the CT group than in the coronary angiography group: 3.6% (1% to 8%) v 10.5% (6% to 16%), P=0.014. CT shortened the median length of stay in the angiography group from 52.9 hours (interquartile range 49.5-76.4 hours) to 30.0 hours (3.5-77.3 hours, P<0.001). Overall median exposure to radiation was similar between the CT and angiography groups: 5.0 mSv (interquartile range 4.2-8.7 mSv) v 6.4 mSv (3.4-10.7 mSv), P=0.45. After a median follow-up of 3.3 years, major adverse cardiovascular events had occurred in seven of 167 patients in the CT group (4.2%) and six of 162 (3.7%) in the coronary angiography group (adjusted hazard ratio 0.90, 95% confidence interval 0.30 to 2.69, P=0.86). 79% of patients stated that they would prefer CT for subsequent testing. The study was conducted at a University hospital in Germany and thus the performance of CT may be different in routine clinical practice. The prevalence was lower than expected, resulting in an underpowered study for the predefined primary outcome. CONCLUSIONS: CT increased the diagnostic yield and was a safe gatekeeper for coronary angiography with no increase in long term events. The length of stay was shortened by 22.9 hours with CT, and patients preferred non-invasive testing.Trial registration ClinicalTrials.gov NCT00844220.
Project description:Background Whether statin treatment can improve hemodynamic status of coronary atherosclerotic plaque remains unknown. It is of clinical interest to explore the hemodynamic change of coronary lesions after statin treatment. Methods and Results Consecutive patients with intermediate pre-test probability of coronary artery disease were prospectively enrolled and underwent baseline coronary computed tomography angiography (CCTA) as well as follow-up CCTA. The primary end point was to determine the lesion-specific change of ?computed tomography-derived fractional flow reserve (?CT-FFR, defined as the change of CT-FFR value across each lesion) after rosuvastatin treatment. The secondary end point was to compare the change of other plaque characteristics according to serial CCTA findings. 152 patients (mean age: 67.1±9.7 years, 100 men, mean follow-up duration of 13.9±2.5 months) were finally included. In non-calcified plaque subgroup, ?CT-FFR was significantly lower at follow-up compared with baseline (0.051±0.010 versus 0.035±0.012, P=0.013). All other parameters were not found to be significantly different between baseline and follow-up CCTA measurements. In calcified plaque and mixed plaque subgroups, all parameters showed no significant differences between baseline and follow-up CCTA groups (P>0.05 for all). According to multivariate regression analysis, non-calcified plaque was >2 times more likely than calcified plaque to observe the decrease of ?CT-FFR (adjusted hazard ratio: 2.05 [1.03-4.09], P=0.042). Conclusions In patients with mild to intermediate coronary stenosis, rosuvastatin treatment resulted in a reduction in lesion-specific ?CT-FFR at mid-term follow-up. This hemodynamic improvement was mainly observed for non-calcified lesions.
Project description:BACKGROUND:Coronary artery bypass grafting (CABG) using saphenous vein grafts (SVG) is vitiated by poor long-term patency of the vein grafts. Pedicled SVG harvested with the "no-touch" (NT) technique have demonstrated improved patency and could confer better outcomes. We aim to compare long-term results after CABG where NT or conventional technique was used for vein graft harvesting in a hypothesis-generating registry-based study. METHODS:Two propensity score matched cohorts (1349 patients) undergoing CABG with veins harvested with NT (NTT) or conventional (CT) technique in Sweden over the period 2005-2015 were used to compare long-term outcomes. Mortality, postoperative incidence of coronary angiography and need for reintervention was recorded and multivariable hazard ratios adjusted for risk factors were calculated. RESULTS:The mean follow-up time (SD) was 6.8 (3.3) years for NTT and 6.6 (3.2) years for CT. The adjusted hazard ratios for death, first angiography and need for reintervention for NTT patients were (95% CI) 0.97 (0.80-1.19), 0.76 (0.63-0.93), 0.91 (0.78-1.05), and 0.91 (0.71-1.17), respectively. Failed grafts were found in 43.2% of NTT patients and 53.6% of CT patients at angiography. CONCLUSIONS:In this study NT grafting was associated with a lower risk for repeat angiography, however no difference could be observed for mortality and need for reintervention. The earlier reported improvements in patency of NT veins could possibly be reflected in an improved clinical outcome during the first 10?years after surgery.
Project description:Coronary CT angiography has high sensitivity, but modest specificity, to detect acute coronary syndrome. We studied whether adding resting CT myocardial perfusion imaging improved the detection of acute coronary syndrome.Patients with low-to-intermediate cardiac risk presenting with possible acute coronary syndrome received both the standard of care evaluation and a research thoracic 64-MDCT examination. Patients with an obstructive (> 50%) stenosis or a nonevaluable coronary segment on CT were diagnosed with possible acute coronary syndrome. CT perfusion was determined by applying gray and color Hounsfield unit maps to resting CT angiography images. Adjudicated patient diagnoses were based on the standard of care and 3-month follow-up. Patient-level diagnostic performance for acute coronary syndrome was calculated for coronary CT, CT perfusion, and combined techniques.A total of 105 patients were enrolled. Of the nine (9%) patients with acute coronary syndrome, all had obstructive CT stenoses but only three had abnormal CT perfusion. CT perfusion was normal in all other patients. To detect acute coronary syndrome, CT angiography had 100% sensitivity, 89% specificity, and a positive predictive value of 45%. For CT perfusion, specificity and positive predictive value were each 100%, and sensitivity was 33%. Combined cardiac CT and CT perfusion had similar specificity but a higher positive predictive value (100%) than did CT angiography.Resting CT perfusion using CT angiographic images may have high specificity and may improve CT positive predictive value for acute coronary syndrome without added radiation and contrast. However, normal resting CT perfusion cannot exclude acute coronary syndrome.
Project description:Cardiac events after revascularization are equally attributable to recurrence at site of culprit lesions and development of nonculprit lesions. We evaluated the hypothesis that coronary computed tomography (CT) angiography and coronary artery calcium score (CACS) performed before revascularization predicts cardiac events after treatment.Among 2238 consecutive patients without known coronary artery disease who underwent coronary CT angiography and CACS, 359 patients underwent revascularization within 30 days after CT; in 337 of 359 (93.9%) follow-up clinical information was available. In addition to known cardiac risk factors, CT findings were evaluated as predictors of cardiac events after revascularization: CACS and the presence of CT-verified high-risk plaque (CT-HRP). Improvement of predictive accuracy by including CT findings was evaluated from a discrimination (Harrell's C-statistics) standpoint. During the follow-up period (median: 673, interquartile range: 47 to 1529 days), a total of 98 cardiac events occurred. Cox proportional hazard model revealed that age, diabetes, triglyceride, CACS, and nonculprit CT-HRP were significant predictors of overall cardiac events. Although not statistically significant, discriminatory power was greater for the model with CACS (C-stat: 63.2%) and the model with both CACS and CT-HRP (65.8%) compared to the model including neither CACS nor CT-HRP (60.7%).High CACS and the presence of nonculprit CT-HRP performed before revascularization are significant predictors of cardiac events after revascularization.
Project description:Background:In the era of High-sensitive troponin (hs-Tn), up to 50% of patients with a mild increase of hs-Tn will finally have a normal invasive coronary angiogram. Fractional Flow Reserve (FFR) derived from coronary computed tomographic angiography (FFR-CT) has never been used as a non-invasive tool for the diagnosis of coronary artery disease in patients with high-risk acute coronary syndrome without ST segment elevation (NSTE-ACS). Aims:The study aims to determine the role of coronary CT angiography and FFR-CT in the setting of high-risk NSTE-ACS. Methodology:We will conduct a prospective trial, enrolling 250 patients admitted with high-risk NSTE-ACS who will rapidly undergo a coronary CT angiography and then a coronary angiography with FFR measurements. Results of coronary CT, FFR-CT and coronary angiography (± FFR) will be compared. Potential significance:In conclusion, non-invasive identification of patients with high-risk NSTE-ACS who could avoid coronary angiography would reduce procedure related risks and medical costs.
Project description:<h4>Rationale</h4>Cases of coronary artery fistula having a connection with the cardiac cavity are rare. Here, we report a case in which 2 coronary arteries empty into the left ventricular cavity together.<h4>Patient concerns</h4>A 63-year-old woman who was diagnosed as having hypertension 20 years prior presented with dyspnea.<h4>Diagnoses</h4>The coronary angiography revealed coronary artery fistula.<h4>Interventions</h4>Chest X-ray showed pulmonary edema. Transthoracic echocardiography revealed moderately decreased left ventricular (LV) function and increased LV end-diastolic volume and mass index. Coronary angiography and cardiac computed tomography revealed that 2 coronary arteries joined together at the distal end and directly drained into the left ventricular cavity bypassing the myocardial capillary vessels. We started medical treatment for heart failure with an angiotensin-converting-enzyme inhibitor, loop diuretic, and spironolactone.<h4>Outcomes</h4>The pulmonary edema improved rapidly. The patient did not experience dyspnea after discharge, and follow-up echocardiography showed improved cardiac function.<h4>Main lesson</h4>Coronary artery fistula could be found incidentally on coronary angiography performed for varied reasons. Physicians must decide carefully whether the fistula needs to be treated in view of the clinical context.
Project description:Background:Coronary artery aneurysms (CAA) are often diagnosed incidentally on coronary angiography or imaging modalities done for other reasons. 'Giant' CAA by definition exceeds 20?mm in diameter or four times the diameter of normal coronary artery. The management of patients with CAAs is challenging due to poorly understood mechanism, variable presentation, and lack of clear-cut societal recommendations. Though conservative management is preferred in asymptomatic patients, massive size or interval growth may make intervention necessary. Case summary:We describe a case of successful coil embolization of a giant coronary aneurysm in an elderly 84-year-old male. Patient, who presented for a follow-up computed tomography angiography to evaluate a previously repaired abdominal aortic aneurysm 2 years back, was found to have interval growth of right coronary artery aneurysm from 4?cm in diameter to 7 × 8?cm in its greatest dimensions. The rationale for treatment was to prevent sudden death from continued growth and eventual rupture of aneurysm in addition to potential risk of thromboembolism and compression of adjacent structures. Discussion:This case demonstrates the safe and successful use of extensive coil embolization technique to treat a 'giant' CAA in an elderly patient when surgical risks were prohibitive.