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Cho et al. (1) should be commended for their recent attempt to answer an important question in an ongoing debate on the prognostic value of coronary computed tomography angiography (CCTA). In their retrospective cohort study from a single center, they concluded that CCTA provided improved discrimination for future major adverse cardiovascular events over the exercise stress test (1). However, it should be noted that:
1. Results of the current study were predominantly based on a clinician-driven outcome—revascularization, which is more amenable to change and should be interpreted with great caution. The difference in prognostic value of the exercise stress test and CCTA (for both negative and positive tests) failed to achieve statistical significance for more relevant clinical outcomes—cardiac death and nonfatal myocardial infarction. Thus, the CCTA-based approach led to a higher rate of revascularization, but it remains unclear whether the CCTA-guided therapeutic decision-making process led to improvement in outcomes in terms of hard clinical endpoints.
2. The researchers censored the outcomes by excluding revascularizations that occurred <90 days after the index test to avoid a confounding effect of CCTA driving the study endpoint. However, such selective removal of patients creates treatment selection bias and results in greater observed risk reduction among patients with obstructions as compared with those without obstructions.
Despite the high radiation exposure, higher cost, unproven clinical benefits, and inability to provide useful clinical information in the settings of high heart rate, coronary calcification, and obesity—which are rampant among patients with coronary artery disease (2)—should we really advocate CCTA as a first-line test for more than 5 million Americans who present to the emergency department every year with chest pain (3)?
- American College of Cardiology Foundation
- Cho I.,
- Shim J.,
- Chang H.J.,
- et al.
- Arbab-Zadeh A.,
- Miller J.M.,
- Rochitte C.E.,
- et al.