Author + information
- Michael C. Honigberg, MD, MPPa,b,c,
- Bradley S. Lander, MDb,c,
- Vinit Baliyan, MBBSd,e,
- Maeve Jones-O’Connor, MB BCh BAOb,c,
- Emma W. Healy, BAa,b,
- Jan-Erik Scholtz, MDd,e,f,
- John T. Nagurney, MD, MPHg,
- Udo Hoffmann, MD, MPHa,d,e,
- Brian B. Ghoshhajra, MD, MBAd,e and
- Pradeep Natarajan, MD, MMSca,b,c,h,i,∗ (, )@pnatarajanmd
- aCardiology Division, Massachusetts General Hospital, Boston, Massachusetts
- bDepartment of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- cDepartment of Medicine, Harvard Medical School, Boston, Massachusetts
- dCardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
- eDepartment of Radiology, Harvard Medical School, Boston, Massachusetts
- fInstitute for Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt, Germany
- gDepartment of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
- hProgram in Medical and Population Genetics, Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, Massachusetts
- iCardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts
- ↵∗Address for correspondence:
Dr. Pradeep Natarajan, Cardiology Division, Massachusetts General Hospital, Harvard Medical School, 185 Cambridge Street, CPZN 3.184, Boston, Massachusetts 02114.
Objectives This study sought to assess medical management of patients found to have nonobstructive coronary artery disease (CAD) on coronary computed tomography angiography (CCTA) performed in the emergency department (ED).
Background Contemporary recognition and management of nonobstructive CAD discovered on CCTA performed in the ED is unknown.
Methods Patients undergoing CCTA in the authors’ hospital’s ED between November 2013 and March 2018 who also received primary care within the authors’ health system were studied. All patients with nonobstructive CAD, defined as 1% to 49% maximum luminal stenosis on CCTA, were included, along with a control group without CAD in a 1 case:1 control fashion. Ten-year atherosclerotic cardiovascular disease (ASCVD) risk prior to CCTA was estimated using the Pooled Cohort Equations. Management changes were recorded until 6 months after CCTA. Multivariate logistic regression tested the association between CCTA result and follow-up statin prescription, adjusting for cardiovascular risk factors and baseline statin use.
Results The cohort included 510 patients with nonobstructive CAD and 510 controls. Prevalence of statin prescription increased from 38.8% to 56.1% among patients with nonobstructive CAD (p < 0.001) and 18.0% to 20.4% among controls (p = 0.01), representing a 7.1-fold relative difference (95% confidence interval [CI]: 4.4 to 23.0; p < 0.001) in multivariate analysis. However, 30.0% of patients with nonobstructive CAD and ≥20% 10-year ASCVD risk were not prescribed a statin at the end of follow-up. Cardiologist evaluation was independently associated with statin prescription after adjustment for ASCVD risk factors (odds ratio [OR] 4.4; 95% CI: 2.4 to 8.5; p < 0.001). A Coronary Artery Disease Reporting and Data System class 1 to 2 result was associated with lower low-density lipoprotein cholesterol by 12.1 mg/dl at mean 1.9-year follow-up (p < 0.001).
Conclusions Incidental subclinical atherosclerosis on CCTA performed in the ED increases the likelihood of statin prescription, but opportunities to improve allocation of indicated preventive therapies remain.
Dr. Hoffmann has received support from Abbott Laboratories, HeartFlow, Kowa Company, and MedImmune; and has received personal fees from Abbott Laboratories. Dr. Nagurney has received research support from Roche, Clendevor, and Quindel/Biosite. Dr. Ghoshhajra has received support from Siemens Healthcare; and is a consultant for Siemens Healthcare and HDL Therapeutics. Dr. Natarajan has received support from the National Heart, Lung, and Blood Institute (K08HL140203) and a Hassenfeld Scholar Award from the Massachusetts General Hospital, Amgen, Apple, and Boston Scientific; and is a consultant for Apple. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 1, 2019.
- Accepted April 26, 2019.
- 2019 American College of Cardiology Foundation
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