Guang-Uei Hung1,2, Kuan-Yin Ko3, Cheng-Li Lin4,5, Ruoh-Fang Yen6,7, Chia-Hung Kao8,9,10. 1. Department of Nuclear Medicine, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan. 2. Department of Biomedical Imaging and Radiological Science, China Medical University, Taichung, Taiwan. 3. Department of Nuclear Medicine, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan. 4. Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan. 5. College of Medicine, China Medical University, Taichung, Taiwan. 6. Department of Nuclear Medicine, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan. rfyen@ntu.edu.tw. 7. Department of Radiology, National Taiwan University College of Medicine, Taipei, Taiwan. rfyen@ntu.edu.tw. 8. Graduate Institute of Clinical Medical Science and School of Medicine, College of Medicine, China Medical University, No. 2, Yuh-Der Road, Taichung, 40447, Taiwan. d10040@mail.cmuh.org.tw. 9. Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan. d10040@mail.cmuh.org.tw. 10. Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan. d10040@mail.cmuh.org.tw.
Abstract
PURPOSE: In patients with stable coronary artery disease (CAD), two main options exist to guide management: initial invasive coronary angiography (CAG), or selective CAG after risk stratification using myocardial perfusion imaging (MPI). This study compared clinical outcomes between these two strategies in a large, real-world population. METHODS: The initial cohort comprised 1,000,000 randomly selected patients who had been entered in the National Health Insurance Research Database of Taiwan between 2000 and 2011. Patients with acute coronary syndromes, prior myocardial infarction (MI) or coronary revascularization, and prior treadmill testing or stress echocardiography were excluded. The remaining patients with suspected or known CAD were divided into those in whom initial CAG had been performed and those in whom initial MPI had been performed, and were followed until the end of 2011 for all-cause mortality, MI, and revascularization. A Cox proportional hazards model was used to estimate the risk of events after adjusting for covariates. RESULTS: The MPI and CAG groups each comprised 4,495 patients after frequency matching, with a similar Charlson comorbidity index (CCI). The MPI group had a significantly and dramatically lower incidence of revascularization (729 vs. 2,380, p < 0.001), MI (268 vs. 1,044, p < 0.001), and all-cause mortality (522 vs. 784, p < 0.001) than the CAG group. Multivariable analysis adjusting for age, gender, CCI, and comorbidities showed that in the MPI group fewer patients had revascularization (HR 0.24, 95% CI 0.22-0.26) and MI (HR 0.23, 95% CI 0.20-0.26), and the rate of all-cause mortality was lower (HR 0.58, 95% CI 0.52-0.64). CONCLUSIONS: In patients with suspected stable CAD, compared with initial invasive CAG, a selective strategy guided by MPI was associated with lower rates of revascularization and MI and improved survival.
PURPOSE: In patients with stable coronary artery disease (CAD), two main options exist to guide management: initial invasive coronary angiography (CAG), or selective CAG after risk stratification using myocardial perfusion imaging (MPI). This study compared clinical outcomes between these two strategies in a large, real-world population. METHODS: The initial cohort comprised 1,000,000 randomly selected patients who had been entered in the National Health Insurance Research Database of Taiwan between 2000 and 2011. Patients with acute coronary syndromes, prior myocardial infarction (MI) or coronary revascularization, and prior treadmill testing or stress echocardiography were excluded. The remaining patients with suspected or known CAD were divided into those in whom initial CAG had been performed and those in whom initial MPI had been performed, and were followed until the end of 2011 for all-cause mortality, MI, and revascularization. A Cox proportional hazards model was used to estimate the risk of events after adjusting for covariates. RESULTS: The MPI and CAG groups each comprised 4,495 patients after frequency matching, with a similar Charlson comorbidity index (CCI). The MPI group had a significantly and dramatically lower incidence of revascularization (729 vs. 2,380, p < 0.001), MI (268 vs. 1,044, p < 0.001), and all-cause mortality (522 vs. 784, p < 0.001) than the CAG group. Multivariable analysis adjusting for age, gender, CCI, and comorbidities showed that in the MPI group fewer patients had revascularization (HR 0.24, 95% CI 0.22-0.26) and MI (HR 0.23, 95% CI 0.20-0.26), and the rate of all-cause mortality was lower (HR 0.58, 95% CI 0.52-0.64). CONCLUSIONS: In patients with suspected stable CAD, compared with initial invasive CAG, a selective strategy guided by MPI was associated with lower rates of revascularization and MI and improved survival.