|
Table IX. The optimal cut-off points,
sensitivities, specificities, positive and negative predictive values, Youden
and accuracy indices, and the negative likelihood ratios of the 6 significant
tested non-invasive and invasive angiography procedural occlusion percentages
for patients who presented with chest pain to QAHI’s Cardiology clinics, RMS,
Amman, Jordan between 1 Jan 2020 to 1 Jan 2021.
|
|
Prognostic Indicator
|
Cutoff
|
TPR
|
FPR
|
YI
|
TNR
|
PPV
|
NPV
|
NLR
|
AI
|
|
%oLADA_CTA
|
47.5%
|
73.90%
|
32.70%
|
41.29%
|
67.35%
|
62.13%
|
78.11%
|
38.69%
|
70.12%
|
|
%oLADA_ICA
|
55%
|
81.70%
|
1.50%
|
80.16%
|
98.47%
|
97.48%
|
88.13%
|
18.59%
|
91.42%
|
|
%oRCA_CTA
|
42.5%
|
35.90%
|
9.70%
|
26.22%
|
90.31%
|
72.86%
|
66.04%
|
70.96%
|
67.46%
|
|
%oRCA_ICA
|
47.5%
|
45.10%
|
3.10%
|
42.01%
|
96.94%
|
91.43%
|
70.90%
|
56.66%
|
75.15%
|
|
%oCxA_CTA
|
15%
|
46.50%
|
26.50%
|
19.95%
|
73.47%
|
55.93%
|
65.45%
|
72.85%
|
62.13%
|
|
%oCxA_ICA
|
45%
|
37.30%
|
1.00%
|
36.30%
|
98.98%
|
96.36%
|
68.55%
|
63.32%
|
73.08%
|
|
⮚ The area under the receiver
operating characteristic (ROC) analysis was constructed against the
propensity for either Percutaneous Invasive (PCI) or Aorto-Coronary Bypass
(ACB) Invasive Strategy (1) versus
Non-Invasive Strategy (0). Sensitivity
analysis was thereafter processed on a total of 1996 processed cases,
142-case were processed as positive actual state, and 196-case were processed
as a negative actual state. 1658 patients who undergone only CTA were dealt
with as missing data. higher values of the test result variable(s) indicate
stronger evidence for a positive actual state. The positive actual state is
the patients who undergone invasive procedures of PCI or ACB.
|
|
TPR: True positive rate (sensitivity).
FPR: False positive rate.
YI: Youden index.
TNR: True negative ratio (specificity).
PPV: Positive predictive value.
NPV: Negative predictive value.
NLR: Negative likelihood ratio.
AI: Accuracy index.
|
LADA: Left Anterior Descending Artery.
RCA: Right Coronary Artery.
CxA: Circumflex artery.
CTA: Coronary Angiography.
ICA: Invasive Coronary Angiography.
|
Discussion
It is increasingly being
recognized that there may not be an ideal diagnostic testing, including ICP,
for prognosticating candidacy of PCI or ACB invasive management modalities over
pharmacotherapeutic interventions. Additionally, the relatively low prevalence
of diagnosed obstructive CAD after pursuing ICA even after positive clinical,
biochemical, and imaging traditional diagnostic tests will actually decreases
the overall picking opportunities for revascularization appropriateness. While
recent appropriateness criteria consider CTA an optimal pre-ICA procedure in
patients with diagnostically ambiguous traditional diagnostic tests, most
studies that investigated the diagnostic utilities of CTA versus ICA were
largely limited to retrospective studies that ambiguously differentiated the
diagnostic performances of CTA and ICA and their sensitivity indices for
invasive over medical treatment propensities.
The uniqueness of our
study was its multidimensional investigated approaches. First, we included all
patients already referred for ICA after CTA based on positive and ambiguous
traditional diagnostic tests which gave this study a generalizability
advantage. Second, owing to moderately functional and anatomical correlations,
we categorized the stenosis percentages on 4 anatomical cardiac sites to
explore the diagnostic capabilities and to differentiate between CTA vs ICA
across 3 compared categorized groups among these 4 studied arteries. Third, in
addition to NPVs and TPRs, we presented other sensitivity indices in this
study, especially TNRs, AIs, PPVs, NLRs, and YIs. Fourth, most previous studies
dichotomized stenosis ranges into 2 primarily levels, ≥50% or <50%. In this study,
we divided the occlusion percentage ranges into 4 levels, 2 levels <50% and
2 levels ≥50%. Dichotomizing ≥50% range into ≥50%-80% and ≥80% ranges may have
a clinical role in prioritizing eligible revascularization patients in over
exhausted situations. Fifth, in our study we explored the operating diagnostic
cutoff points of occlusion percentages for the 3 investigated cardiac arteries
and for the 2 studied diagnostic procedures to prognosticate the propensity of
invasive revascularization strategy over non-invasive medical treatment.
Given the clinical
importance of early discrimination obstructive CAD from other non-CAD similar
presentation symptoms, several studies have investigated CTA after positive
traditional diagnostic tests in different groups. For example, the Advanced
Cardiovascular Imaging Consortium (ACIC) registry included 3,623 patients with
positive diagnostic test results but reported significant composite cardiac
vascular stenosis (>50%) in only 19.7% of studied patients. [13-14] In
our study, we explored a much higher average incidences of stenosis percentages
(≥50%-80% and ≥80%) as assessed by the sequential tested diagnostic procedures
(CTA and ICA) in LADA, RCA, and CxA with counts (%) of {[123 (36.3%) and 46 (13.6%) vs 44 (13.0%) and 81 (24.0%)],
[47 (13.9%) and 22 (6.5%) vs 26 (7.7%) and 44 (13.0%)], and [35 (10.3%) and 14 (4.1%)
vs 20 (5.9%) and 34 (10.1%)]}. The higher findings in this study
compared to the aforementioned study may be owing to higher prevalence of CADs
in our country and due to a more risky attended patients to our specialized
cardiac institute.
Other previous studies
have had inconsistencies regarding the diagnostic performance of CTA versus
ICA. For example, a subgroup of 621 patients, according to ACIC registry, who
underwent both CCTA and ICA after stress testing had substantially lower values
for TPR, TNR, PPV and NPV of 93.7%, 37.9%, 70.6% and 79.1% respectively. [15-18] In our study, we assessed a substantially different sensitivity
indices compared to results of ACIC registry. The TPRs, TNRs, PPVs, NPVs for
patients who presented with chest pain to QAHI’s Cardiology clinics, and were
intervened with the dual diagnostic procedures of CTA and ICA on the LADA, RCA,
CxA were [(73.90%, 67.35%, 62.13%, and 78.11%) vs (81.70%,
98.47%, 97.48%, and 88.13%) vs (35.90%, 90.31%,
72.86%, and 66.04%) vs (45.10%, 96.94%,
91.43%, and 70.90%) vs (46.50%, 73.47%,
55.93%, and 65.45%) vs (37.30%, 98.98%,
96.36%, and 68.55%)].
Low-dose CTA was found to have an
acceptable comparable sensitivity to ICT in our study and is universally
suggested as an alternative to ICT for triaging patients with suspected
coronary artery disease. [19-20] More
recently, ultra-high-resolution CT scan devices yielded excellent correlation
between CT and ICA results. Further research is underway comparing
ultra-high-resolution CT scan. Finally, this study show that coronary CTA
results showed good concordance with ICA findings, and that it is specifically
useful in ruling out cases with no stenosis, supporting the role of coronary
CTA as a diagnostic test in suspected coronary artery disease.
Strength and limitations of the
study:
This
study is limited by its retrospective design, using single-center data.
Nonetheless, our specialized cardiac center is an experienced and high-volume
unit, so our data may be useful in other centers. A larger, multisite, and
prospective study is needed to control for multiple confounders.
CONCLUSION
Despite
the limitations of coronary CTA being a diagnostic test compared to ICA where
interventional treatment could be performed, CTA based diagnostic procedure may have practically a unique early diagnostic and prognostic
value in patients who presented with chest pain with variable sensitivity
analysis indices in the era of global over and ever-shrinking in
medical teams and facilities to make sure optimum resource provision and
implement swift management protocols.
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