J Cardiovasc Comput Tomogr. 2014 Nov-Dec;8(6):480-2. doi: 10.1016/j.jcct.2014.10.002. Epub 2014 Oct 15.
Cury RC.
A common practice in cardiology and medicine is to identify which patients who are presenting with stable chest pain symptoms actually have obstructive coronary artery disease (CAD). A detailed clinical history and physical examination are critical to determine the patient's pretest probability of CAD. Noninvasive diagnostic testing is commonly used, particularly in intermediate-risk patients, to determine which patients have abnormal findings for subsequent referral for invasive coronary angiography (ICA). The overall goal is to identify patients with obstructive CAD and/or myocardial ischemia who will benefit from coronary revascularization that may lead to improving clinical outcomes.
Patel et al first reported a low diagnostic yield of elective ICA to detect obstructive CAD in the CathPCI Registry of the National Cardiovascular Data Registry involving almost 400,000 patients. Only 37.6% of patients had obstructive CAD, whereas 39.2% of patients were reported with no CAD (defined as <20% in all vessels). What is also alarming is that 83.9% of patients had a prior noninvasive testing, but a positive result on noninvasive testing had only limited effect on the C statistic model's predictive ability over and above the effect achieved from the addition of clinical risk factors and symptoms. Unfortunately, the information regarding noninvasive testing was lumped together in the article, but we can only assume that most patients assessed during the study period from 2004 to 2008 had noninvasive stress tests (predominantly, exercise and nuclear single-photon emission CT [SPECT]). The authors conclude from this large registry that current strategies, including clinical assessment of risk and the used noninvasive testing, are limited and that a substantial improvement in triaging patients to the cardiac catheterization laboratory is needed.
Full Article: http://www.sciencedirect.com/science/article/pii/S1934592514002597