Gianluca Pontone1, Daniele Andreini2, Andrea I Guaricci2, Cristina Rota2, Marco Guglielmo2, Saima Mushtaq2, Andrea Baggiano2, Virginia Beltrama2, Laura Fusini2, Anna Solbiati2, Chiara Segurini2, Edoardo Conte2, Paola Gripari2, Andrea Annoni2, Alberto Formenti2, Maria Petulla'2, Federico Lombardi2, Giuseppe Muscogiuri2, Antonio L Bartorelli2, Mauro Pepi2. 1. From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.). gianluca.pontone@ccfm.it. 2. From the Centro Cardiologico Monzino, IRCCS, Milan, Italy (G.P., D.A., C.R., M.G., S.M., A.B., V.B., L.F., A.S., C.S., E.C., P.G., A.A., A.F., M.P., A.L.B., M.P.); Department of Cardiovascular Sciences and Community Health, University of Milan, Italy (D.A., C.R., A.B., A.S., C.S., F.L.); Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital "Policlinico Consorziale" of Bari, Italy (A.I.G.); Department of Medical and Surgical Sciences, University of Foggia, Italy (A.I.G.); UOC Malattie Cardiovascolari, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy (F.L.); and Department of Imaging, Bambino Gesù-Children's Hospital IRCCS, Rome, Italy (G.M.); Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Italy (A.L.B.).
Abstract
BACKGROUND: Computed tomography coronary angiography (cTCA) and stress cardiac magnetic resonance (stress-CMR) are suitable tools for diagnosing obstructive coronary artery disease in symptomatic patients with previous history of revascularization. However, performance appraisal of noninvasive tests must take in account the consequent diagnostic testing, invasive procedures, clinical outcomes, radiation exposure, and cumulative costs rather than their diagnostic accuracy only. We aimed to compare an anatomic (cTCA) versus a functional (stress-CMR) strategy in symptomatic patients with previous myocardial revascularization procedures. METHODS AND RESULTS: Six hundred patients with chest pain and previous revascularization included in a prospective observational registry and evaluated by clinically indicated cTCA (n=300, mean age 68.2±9.7 years, male 255) or stress-CMR (n=300, mean age 67.6±9.7 years, male 263) were enrolled and followed-up in terms of subsequent noninvasive tests, invasive coronary angiography, revascularization procedures, cumulative effective radiation dose, major adverse cardiac events, defined as a composite end point of nonfatal myocardial infarction and cardiac death, and medical costs. The mean follow-up for cTCA and stress-CMR groups was similar (773.6±345 versus 752.8±291 days; P=0.21). Compared with stress-CMR, cTCA was associated with a higher rate of subsequent noninvasive tests (28% versus 17%; P=0.0009), invasive coronary angiography (31% versus 20%; P=0.0009), and revascularization procedures (24% versus 16%; P=0.007). Stress-CMR strategy was associated with a significant reduction of radiation exposure and cumulative costs (59% and 24%, respectively; P<0.001). Finally, patients undergoing stress-CMR showed a lower rate of major adverse cardiac events (5% versus 10%; P<0.010) and cost-effectiveness ratio (119.98±250.92 versus 218.12±298.45 Euro/y; P<0.001). CONCLUSIONS: Compared with cTCA, stress-CMR is more cost-effective in symptomatic revascularized patients.
BACKGROUND: Computed tomography coronary angiography (cTCA) and stress cardiac magnetic resonance (stress-CMR) are suitable tools for diagnosing obstructive coronary artery disease in symptomatic patients with previous history of revascularization. However, performance appraisal of noninvasive tests must take in account the consequent diagnostic testing, invasive procedures, clinical outcomes, radiation exposure, and cumulative costs rather than their diagnostic accuracy only. We aimed to compare an anatomic (cTCA) versus a functional (stress-CMR) strategy in symptomatic patients with previous myocardial revascularization procedures. METHODS AND RESULTS: Six hundred patients with chest pain and previous revascularization included in a prospective observational registry and evaluated by clinically indicated cTCA (n=300, mean age 68.2±9.7 years, male 255) or stress-CMR (n=300, mean age 67.6±9.7 years, male 263) were enrolled and followed-up in terms of subsequent noninvasive tests, invasive coronary angiography, revascularization procedures, cumulative effective radiation dose, major adverse cardiac events, defined as a composite end point of nonfatal myocardial infarction and cardiac death, and medical costs. The mean follow-up for cTCA and stress-CMR groups was similar (773.6±345 versus 752.8±291 days; P=0.21). Compared with stress-CMR, cTCA was associated with a higher rate of subsequent noninvasive tests (28% versus 17%; P=0.0009), invasive coronary angiography (31% versus 20%; P=0.0009), and revascularization procedures (24% versus 16%; P=0.007). Stress-CMR strategy was associated with a significant reduction of radiation exposure and cumulative costs (59% and 24%, respectively; P<0.001). Finally, patients undergoing stress-CMR showed a lower rate of major adverse cardiac events (5% versus 10%; P<0.010) and cost-effectiveness ratio (119.98±250.92 versus 218.12±298.45 Euro/y; P<0.001). CONCLUSIONS: Compared with cTCA, stress-CMR is more cost-effective in symptomatic revascularized patients.
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