Comprehensive Cardiac CT Versus Exercise Testing in Suspected Coronary Artery Disease 2 - CRESCENT-II

Dec 07, 2018
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Author/Summarized by Author:
Anthony A. Bavry, MD,MPH,FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Trial Sponsor:
Erasmus Medical Center and ZonMW
Date Published:
11/05/2018
Date Updated:
12/07/2018
Original Posted Date:
12/07/2018
References

Contribution To Literature:

The CRESCENT-II trial showed that tiered cardiac CT was an alternative strategy to functional testing among stable angina patients.

Description:

The goal of the trial was to evaluate a strategy of tiered cardiac computed tomography (CT) compared with functional testing among patients with stable angina symptoms.

Study Design

  • Randomized
  • Parallel

Patients with stable angina were randomized to cardiac CT (n = 130) versus functional testing (n = 138). In the cardiac CT group, testing began with calcium scoring, followed by CT angiography if calcium was detected, followed by CT perfusion imaging if ≥50% stenosis was detected. In the functional testing group, 95% underwent exercise electrocardiography.

  • Total number of enrollees: 268
  • Duration of follow-up: 6 months
  • Mean patient age: 58 years
  • Percentage female: 49%
  • Percentage with diabetes: 18%

Inclusion criteria:

  • Patients ≥18 years of age with stable angina symptoms

Exclusion criteria:

  • Prior myocardial infarction or revascularization procedure
  • Chronic kidney disease
  • Iodine allergy
  • Contraindication to adenosine
  • Known pregnancy

Principal Findings:

The primary outcome, proportion of angiograms without a European Society of Cardiology class I indication for revascularization, was 1.5% in the cardiac CT group compared with 7.2% in the functional testing group (p = 0.035).

Secondary outcomes:

  • Invasive angiograms: 13.1% in the cardiac CT group vs. 14.5% in the functional testing group (p = 0.86).
  • Proportion of angiograms with a class I indication for revascularization: 11.5% in the cardiac CT group vs. 7.2% in the functional testing group (p = 0.29)
  • Positive diagnostic yield of invasive angiography: 88.2% in the cardiac CT group vs. 50.0% in the functional testing group (p = 0.017)
  • Median time until final diagnosis: 0 days in both groups
  • Adverse event rate: 3% in the cardiac CT group vs. 3% in the functional testing group (p = 1.0)

Interpretation:

Among patients with stable angina symptoms, tiered cardiac CT was a safe and efficient strategy compared to functional testing. Cardiac CT was associated with a reduction in the proportion of angiograms without a class I indication for revascularization. Cardiac CT was also associated with a greater positive diagnostic yield of invasive angiography. Both strategies were efficient and safe. Tiered cardiac CT is an alternative strategy to functional testing among stable angina patients. 

References:

Lubbers M, Coenen A, Kofflard M, et al. Comprehensive Cardiac CT With Myocardial Perfusion Imaging Versus Functional Testing in Suspected Coronary Artery Disease. JACC Cardiovasc Imaging 2018;11:1625-1636.

Editorial Comment: Shaw LJ, Narula J, Chandrashekhar Y. The Shape of Imaging in the Future: Lessons Learned From the CRESCENT II Trial. JACC Cardiovasc Imaging 2018;11:1637-1639.

Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Stable Ischemic Heart Disease, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and SIHD, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Computed Tomography, Nuclear Imaging, Chronic Angina

Keywords: Angina, Stable, Angiography, Coronary Angiography, Constriction, Pathologic, Coronary Artery Disease, Diagnostic Imaging, Exercise Test, Myocardial Ischemia, Myocardial Perfusion Imaging, Myocardial Revascularization, Tomography, X-Ray Computed


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