Author + information
- Received February 13, 2017
- Revision received September 26, 2017
- Accepted October 6, 2017
- Published online November 5, 2018.
- Marisa Lubbers, MDa,b,∗ (, )
- Adriaan Coenen, MDa,b,
- Marcel Kofflard, MD, PhDc,
- Tobias Bruning, MD, PhDd,
- Bas Kietselaer, MD, PhDe,
- Tjebbe Galema, MD, PhDa,
- Marc Kock, MD, PhDf,
- Andre Niezen, MD, PhDg,
- Marco Das, MD, PhDh,
- Marco van Gent, MDc,
- Ewout-Jan van den Bos, MD, PhDc,
- Leon van Woerkens, MD, PhDc,
- Paul Musters, MANPa,
- Suze Kooij, BScf,
- Fay Nous, MDb,
- Ricardo Budde, MD, PhDb,
- Miriam Hunink, MD, PhDb and
- Koen Nieman, MD, PhDa,b,i
- aDepartment of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
- bDepartment of Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands
- cDepartment of Cardiology, Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
- dDepartment of Cardiology, Maasstad Ziekenhuis, Rotterdam, the Netherlands
- eDepartment of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands
- fDepartment of Radiology, Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
- gDepartment of Radiology, Maasstad Ziekenhuis, Rotterdam, the Netherlands
- hDepartment of Radiology, Maastricht University Medical Center, Maastricht, the Netherlands
- iStanford Cardiovascular Institute, Stanford University, Palo Alto, California
- ↵∗Address for correspondence:
Dr. Marisa Lubbers, Department of Cardiology, Erasmus Medical Center, 's-Gravendijkwal 230, Room Ca-207a, 3015 CE Rotterdam, the Netherlands.
Objectives This study sought to assess the effectiveness, efficiency, and safety of a tiered, comprehensive cardiac computed tomography (CT) protocol in comparison with functional testing.
Background Although CT angiography accurately rules out coronary artery disease (CAD), incorporation of CT myocardial perfusion imaging as part of a tiered diagnostic approach could improve the clinical value and efficiency of cardiac CT in the diagnostic work-up of patients with angina pectoris.
Methods Between July 2013 and November 2015, 268 patients (mean age 58 years; 49% female) with stable angina (mean pre-test probability 54%) were prospectively randomized between cardiac CT and standard guideline-directed functional testing (95% exercise electrocardiography). The tiered cardiac CT protocol included a calcium scan, followed by CT angiography if calcium was detected. Patients with ≥50% stenosis on CT angiography underwent CT myocardial perfusion imaging.
Results By 6 months, the primary endpoint, the rate of invasive coronary angiograms without a European Society of Cardiology class I indication for revascularization, was lower in the CT group than in the functional testing group (2 of 130 [1.5%] vs. 10 of 138 [7.2%]; p = 0.035), whereas the proportion of invasive angiograms with a revascularization indication was higher (88% vs. 50%; p = 0.017). The median duration until the final diagnosis was 0 (0 of 0) days in the CT group and 0 (0 of 17) in the functional testing group (p < 0.001). Overall, 13% of patients randomized to CT required further testing, compared with 37% in the functional testing group (p < 0.001). The adverse event rate was similar (3% vs. 3%; p = 1.000), although the median cumulative radiation dose was higher for the CT group (3.1 mSv [interquartile range: 1.6 to 7.8] vs. 0 mSv [interquartile range: 0.0 to 7.1]; p < 0.001).
Conclusions In patients with suspected stable CAD, a tiered cardiac CT protocol with dynamic perfusion imaging offers a fast and efficient alternative to functional testing. (Comprehensive Cardiac CT Versus Exercise Testing in Suspected Coronary Artery Disease 2 [CRESCENT2]; NCT02291484)
- coronary CT angiography
- CT calcium scan
- CT myocardial perfusion imaging
- diagnostic testing
- functional testing
- stable angina
This work was supported by the Erasmus University Medical Center and ZonMW. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Dr. Lubbers is supported by a grant from the Dutch Heart Foundation (NHS 2014T061). Dr. Coenen is supported by a grant from the Dutch Heart Foundation (NHS 2014T061). Dr. Das has received institutional grant support from and has been a speaker for Siemens, Bayer, Philips, and Cook. Dr. Nieman is supported by a grant from the Dutch Heart Foundation (NHS 2014T061); has received institutional research support from Siemens, General Electric Healthcare, Bayer, and HeartFlow; and has received speaker fees from Siemens. Dr. Hunink has received personal research support from Cambridge University Press; has received grants and nonfinancial support from the European Society of Radiology; and has received nonfinancial support from the European Institute for Biomedical Imaging Research, outside the submitted work. Dr. Kietselaer has received institutional research support from AstraZeneca and Bayer; was supported by internal research grants from Maastricht University Medical Center; and has received speaker fees from Astellas and Amgen. All other authors have reported that they have relationships relevant to this paper to disclose.
- Received February 13, 2017.
- Revision received September 26, 2017.
- Accepted October 6, 2017.
- 2018 American College of Cardiology Foundation