Perspective:

Studies have clearly demonstrated that a majority of patients undergoing ICA do not have obstructive CAD, which has prompted calls for better strategies to avoid unnecessary ICA in patients with suspected CAD and stable symptoms. This large multicenter study finds that patients referred for elective ICA who instead were randomized to initial CCTA had low rates of ICA utilization following CCTA, lower rates of revascularization, and similar rates of adverse events at 1 year. One advantage of this study is that the CCTA arm utilized a real-world approach, with providers deciding whether or not to proceed with subsequent ICA based on their clinical judgment and using the CCTA findings as a “gatekeeper” prior to ICA. These findings suggest that considering CCTA prior to elective ICA could reduce unnecessary procedures and result in similar outcomes, and should be considered in clinical practice and future guidelines.