CORRESPONDENCE: LETTER TO THE EDITOR
Placing Computed Tomography Coronary Angiography in Perspective
James K. Min, MD* and
Daniel S. Berman, MD
* Weill Medical College of Cornell University, New York Presbyterian Hospital, Department of Medicine (Cardiology) and Radiology, 520 East 70th Street, K415, New York, New York 10021 (Email: jkm2001{at}med.cornell.edu).
The study in the Journal by Meijboom et al. (1) and the accompanying editorial by Nissen (2) seem disconnected from each other.
The Meijboom et al. (1) study was a diagnostic performance study that aimed to establish the accuracy of the newly introduced technology. This was a well-executed prospective multicenter, multivendor study, the results of which indicate high diagnostic accuracy of computed tomography coronary angiography (CTCA) in symptomatic patients with a high prevalence of coronary artery disease (CAD) that is superior to other methods of noninvasive cardiac testing. Furthermore, despite the high prevalence of significant CAD, the ability of CTCA to exclude obstructive coronary stenosis in the Meijboom et al. (1) study approached 100%, which is higher than that reported for all other forms of noninvasive cardiac testing.
In contrast, the accompanying editorial by Nissen (2) briefly discusses the Meijboom et al. (1) study but concentrated much of its text to describing the history of invasive coronary angiography, stress testing, CTCA, and the need for patient-centered outcomes studies for CTCA.
There are several important observations that are worthy of note: - 1 The cart should not be placed before the horse. The first step for assessment of any new diagnostic technology is the establishment of its diagnostic accuracy, and this purpose was well served by the Meijboom et al. (1) study. Indeed, the Meijboom et al. (1) study now joins 2 other prospective multicenter studies (ACCURACY [Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography] and CORE-64 [Coronary Artery Evaluation Using 64-Row Multidetector Computed Tomography Angiography]) evaluating the accuracy of CTCA (3,4). There have been no large-scale, prospective, multicenter studies of diagnostic accuracy performed for the stress imaging tests that have become the de facto standard of care.
- 2 "When will we get there?" is a fair question. "Why aren't we there?" is not. The introduction of CTCA occurred 3 years ago, just enough time to definitively establish diagnostic accuracy. Studies regarding CTCA now need to assess its costs to the health care system and its clinical effectiveness for patients, and these types of trials have been proposed and designed and are being implemented.
- 3 "Res ipsa loquitur." Until these trials can be completed, common sense should dictate clinical use of noninvasive cardiac testing. The majority of patients for whom noninvasive cardiac testing is most appropriate will not have significant CAD. As such, a test that can successfully exclude CAD with an accuracy approaching 100% should be employed to identify individuals in which no further need for testing or therapy is necessary. With its very high negative predictive value, an immediate benefit of the use of this test would be to eliminate the need for unnecessary invasive coronary angiography.
- 4 Negative is not necessarily bad. Although it is a complex task to ascribe an economic value to the intangibles of a negative test in a scientific study, it is nevertheless very straightforward to a patient. A "negative test" can be worth as much—if not more—than a "positive test," because the value of peace of mind to a concerned symptomatic patient is unambiguous: it is priceless.
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Footnotes
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Please note: Dr. Min serves on the Speakers' Bureau for GE Healthcare and receives research support from GE Healthcare and Vital Images.
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References
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1. Meijboom WB, Meijs MF, Schiujf JD, et al. Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study J Am Coll Cardiol 2008;52:2135-2144.[Abstract/Free Full Text]2. Nissen SE. Limitations of computed tomography coronary angiography J Am Coll Cardiol 2008;52:2145-2147.[Free Full Text] 3. Budoff MJ, Dowe D, Jollis JG, et al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial J Am Coll Cardiol 2008;52:1724-1732.[Abstract/Free Full Text] 4. Miller JM, Rochitte CE, Dewey M, et al. Diagnostic performance of coronary angiography by 64-row CT N Engl J Med 2008;359:2324-2336.[Abstract/Free Full Text]
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