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Coronary CT Angiography in Non–ST-Elevation Acute Coronary Syndromes
Quick Takes
- Coronary CT angiography findings in patients with non–ST-elevation acute coronary syndromes (NSTEACS) provide similar prognostic value compared to invasive angiography.
- The presence of obstructive or high-risk coronary artery disease on coronary CT angiography is associated with greater adverse events in NSTEACS.
Study Questions:
Do findings on coronary computed tomography angiography (CTA) in patients with non–ST-elevation acute coronary syndrome (NSTEACS) identify patients at elevated risk of adverse events?
Methods:
The VERDICT (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography) trial examined the relationship between timing of invasive angiography in patients with NSTEACS and clinical outcomes; a blinded coronary CTA was performed prior to invasive angiography. In the observational part of this study, the presence of obstructive (≥50% stenosis) versus nonobstructive coronary artery disease (CAD) and the presence of high-risk disease (obstructive disease of the left main, proximal left anterior descending artery, and/or multiple vessels) versus non–high-risk disease were compared to the rate of primary events (all-cause mortality, recurrent myocardial infarction, hospital admission for ischemia, or heart failure).
Results:
Both coronary CTA and invasive angiography were performed in 978 patients, and adverse events occurred in 208 patients over a median follow-up of 4.2 years. Obstructive CAD was reported in 73% and 67% of patients by CTA and invasive angiography, while high-risk disease was reported in 51% and 37% of patients, respectively. The rate of the primary endpoint was higher in patients with obstructive (vs. nonobstructive) CAD as identified by CTA (hazard ratio [HR], 1.7; 95% confidence interval [CI], 1.2-2.5; p = 0.002) and invasive angiography (HR, 1.5; 95% CI, 1.1-2.1; p = 0.007), and was also higher in patients with (vs. without) high-risk disease on CTA (HR, 1.6; 95% CI, 1.2-2.1; p = 0.002), but not on invasive angiography (HR, 1.3; 95% CI, 1.0-1.7; p = 0.07).
Conclusions:
Coronary CTA findings in patients with NSTEACS provide similar prognostic value in comparison to invasive coronary angiography.
Perspective:
This study finds that the presence of obstructive or high-risk CAD on coronary CTA in patients with NSTEACS has prognostic value and identified patients at increased risk of adverse events in a similar manner as invasive coronary angiography. Interestingly, the presence of high-risk findings on coronary CTA was significantly associated with the primary endpoint, while the presence of these findings on invasive angiography did not meet statistical significance. Coronary CTA reported slightly higher rates of obstructive CAD compared to invasive angiography (73% vs. 67%), but reported markedly higher rates of high-risk disease (51% vs. 37%), which could relate to identification of plaque on CTA that may be underappreciated on invasive angiography, as well as differences between the clinical visual assessment used for invasive angiography and the core lab consensus analysis used for CTA findings. This study uses coronary CTA in a relatively limited manner and does not evaluate for the presence of other potentially high-risk findings such as low-attenuation plaque, positive remodeling, and plaque burden, which could potentially further increase the prognostic value of CTA findings.
Clinical Topics: Acute Coronary Syndromes, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Acute Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Computed Tomography, Nuclear Imaging
Keywords: Acute Coronary Syndrome, Constriction, Pathologic, Coronary Angiography, Coronary Artery Disease, Diagnostic Imaging, Heart Failure, Myocardial Infarction, Myocardial Ischemia, Plaque, Atherosclerotic, Prognosis, Risk Assessment, Tomography, X-Ray Computed
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