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Selective Referral Using CCTA Versus Direct Referral for Individuals Referred to Invasive Coronary Angiography for Suspected CAD: A Randomized, Controlled, Open-Label Trial

 Hyuk-Jae Chang  ;  Fay Y. Lin  ;  Dan Gebow  ;  Hae Young An  ;  Daniele Andreini  ;  Ravi Bathina  ;  Andrea Baggiano  ;  Virginia Beltrama  ;  Rodrigo Cerci  ;  Eui-Young Choi  ;  Jung-Hyun Choi  ;  So-Yeon Choi  ;  Namsik Chung  ;  Jason Cole  ;  Joon-Hyung Doh  ;  Sang-Jin Ha  ;  Ae-Young Her  ;  Cezary Kepka  ;  Jang-Young Kim  ;  Jin-Won Kim  ;  Sang-Wook Kim  ;  Woong Kim  ;  Gianluca Pontone  ;  Uma Valeti  ;  Todd C. Villines  ;  Yao Lu  ;  Amit Kumar  ;  Iksung Cho  ;  Ibrahim Danad  ;  Donghee Han  ;  Ran Heo  ;  Sang-Eun Lee  ;  Ji Hyun Lee  ;  Hyung-Bok Park  ;  Ji-min Sung  ;  David Leflang  ;  Joseph Zullo  ;  Leslee J. Shaw  ;  James K. Min 
 JACC. Cardiovascular Imaging, Vol.12(7) : 1303-1312, 2019 
Journal Title
 JACC. Cardiovascular Imaging 
Issue Date
coronary computed tomographic angiography ; invasive coronary angiography ; major adverse cardiac events ; stable ischemic heart disease
OBJECTIVES: This study compared the safety and diagnostic yield of a selective referral strategy using coronary computed tomographic angiography (CCTA) compared with a direct referral strategy using invasive coronary angiography (ICA) as the index procedure. BACKGROUND: Among patients presenting with signs and symptoms suggestive of coronary artery disease (CAD), a sizeable proportion who are referred to ICA do not have a significant, obstructive stenosis. METHODS: In a multinational, randomized clinical trial of patients referred to ICA for nonemergent indications, a selective referral strategy was compared with a direct referral strategy. The primary endpoint was noninferiority with a multiplicative margin of 1.33 of composite major adverse cardiovascular events (blindly adjudicated death, myocardial infarction, unstable angina, stroke, urgent and/or emergent coronary revascularization or cardiac hospitalization) at a median follow-up of 1-year. RESULTS: At 22 sites, 823 subjects were randomized to a selective referral and 808 to a direct referral strategy. At 1 year, selective referral met the noninferiority margin of 1.33 (p = 0.026) with a similar event rate between the randomized arms of the trial (4.6% vs. 4.6%; hazard ratio: 0.99; 95% confidence interval: 0.66 to 1.47). Following CCTA, only 23% of the selective referral arm went on to ICA, which was a rate lower than that of the direct referral strategy. Coronary revascularization occurred less often in the selective referral group compared with the direct referral to ICA (13% vs. 18%; p < 0.001). Rates of normal ICA were 24.6% in the selective referral arm compared with 61.1% in the direct referral arm of the trial (p < 0.001). CONCLUSIONS: In stable patients with suspected CAD who are eligible for ICA, the comparable 1-year major adverse cardiovascular events rates following a selective referral and direct referral strategy suggests that both diagnostic approaches are similarly effective. In the selective referral strategy, the reduced use of ICA was associated with a greater diagnostic yield, which supported the usefulness of CCTA as an efficient and accurate method to guide decisions of ICA performance. (Coronary Computed Tomographic Angiography for Selective Cardiac Catheterization [CONSERVE]; NCT01810198).
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1. College of Medicine (의과대학) > Dept. of Internal Medicine (내과학교실) > 1. Journal Papers
Yonsei Authors
Sung, Ji Min(성지민)
Chang, Hyuk-Jae(장혁재) ORCID logo https://orcid.org/0000-0002-6139-7545
Chung, Nam Sik(정남식)
Han, Donghee(한동희)
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