Roxy Senior1, Harmony R Reynolds2, James K Min3, Daniel S Berman4, Michael H Picard5, Bernard R Chaitman6, Leslee J Shaw3, Courtney B Page7, Sajeev C Govindan8, Jose Lopez-Sendon9, Jesus Peteiro10, Gurpreet S Wander11, Jaroslaw Drozdz12, Jose Marin-Neto13, Joseph B Selvanayagam14, Jonathan D Newman2, Christophe Thuaire15, Johann Christopher16, James J Jang17, Raymond Y Kwong18, Sripal Bangalore2, Gregg W Stone19, Sean M O'Brien7, William E Boden20, David J Maron21, Judith S Hochman2. 1. Northwick Park Hospital-Royal Brompton Hospital, London, United Kingdom. Electronic address: roxysenior@cardiac-research.org. 2. New York University Grossman School of Medicine, New York, New York, USA. 3. Cleerly, Inc, New York, New York, USA. 4. Cedars-Sinai Medical Center, Los Angeles, California, USA. 5. Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA. 6. St Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St Louis, Missouri, USA. 7. Duke Clinical Research Institute, Durham, North Carolina, USA. 8. Government Medical College, Calicut, India. 9. Hospital Universitario La Paz, Idipaz, UAM, CIBER-CV, Madrid, Spain. 10. CHUAC, Universidad de A Coruña, CIBER-CV, A Coruna, Spain. 11. Dayanand Medical College & Hospital, Punjab, India. 12. Department Cardiology Medical University, Lodz, Poland. 13. Hospital das Clinicas da Faculdade de Medicina de Ribeirao Preto da Universidade de Sao Paulo, Sao Paulo, Brazil. 14. Flinders Medical Centre, Adelaide, South Australia, Australia. 15. C.H. Louis Pasteur, Le Coudray, France. 16. CARE Hospital, Hyderabad, India. 17. Kaiser Permanente/San Jose Medical Center, San Jose, California, USA. 18. Brigham and Women's Hospital, Boston, Massachusetts, USA. 19. Icahn School of Medicine at Mount Sinai, Cardiovascular Research Foundation, New York, New York, USA. 20. VA New England Healthcare System, Boston University School of Medicine, Boston, Massachusetts, USA. 21. Department of Medicine, Stanford University School of Medicine, Stanford, California, USA.
Abstract
BACKGROUND: Detection of ≥50% diameter stenosis left main coronary artery disease (LMD) has prognostic and therapeutic implications. Noninvasive stress imaging or an exercise tolerance test (ETT) are the most common methods to detect obstructive coronary artery disease, though stress test markers of LMD remain ill-defined. OBJECTIVES: The authors sought to identify markers of LMD as detected on coronary computed tomography angiography (CTA), using clinical and stress testing parameters. METHODS: This was a post hoc analysis of ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches), including randomized and nonrandomized participants who had locally determined moderate or severe ischemia on nonimaging ETT, stress nuclear myocardial perfusion imaging, or stress echocardiography followed by CTA to exclude LMD. Stress tests were read by core laboratories. Prior coronary artery bypass grafting was an exclusion. In a stepped multivariate model, the authors identified predictors of LMD, first without and then with stress testing parameters. RESULTS: Among 5,146 participants (mean age 63 years, 74% male), 414 (8%) had LMD. Predictors of LMD were older age (P < 0.001), male sex (P < 0.01), absence of prior myocardial infarction (P < 0.009), transient ischemic dilation of the left ventricle on stress echocardiography (P = 0.05), magnitude of ST-segment depression on ETT (P = 0.004), and peak metabolic equivalents achieved on ETT (P = 0.001). The models were weakly predictive of LMD (C-index 0.643 and 0.684). CONCLUSIONS: In patients with moderate or severe ischemia, clinical and stress testing parameters were weakly predictive of LMD on CTA. For most patients with moderate or severe ischemia, anatomical imaging is needed to rule out LMD. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).
BACKGROUND: Detection of ≥50% diameter stenosis left main coronary artery disease (LMD) has prognostic and therapeutic implications. Noninvasive stress imaging or an exercise tolerance test (ETT) are the most common methods to detect obstructive coronary artery disease, though stress test markers of LMD remain ill-defined. OBJECTIVES: The authors sought to identify markers of LMD as detected on coronary computed tomography angiography (CTA), using clinical and stress testing parameters. METHODS: This was a post hoc analysis of ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches), including randomized and nonrandomized participants who had locally determined moderate or severe ischemia on nonimaging ETT, stress nuclear myocardial perfusion imaging, or stress echocardiography followed by CTA to exclude LMD. Stress tests were read by core laboratories. Prior coronary artery bypass grafting was an exclusion. In a stepped multivariate model, the authors identified predictors of LMD, first without and then with stress testing parameters. RESULTS: Among 5,146 participants (mean age 63 years, 74% male), 414 (8%) had LMD. Predictors of LMD were older age (P < 0.001), male sex (P < 0.01), absence of prior myocardial infarction (P < 0.009), transient ischemic dilation of the left ventricle on stress echocardiography (P = 0.05), magnitude of ST-segment depression on ETT (P = 0.004), and peak metabolic equivalents achieved on ETT (P = 0.001). The models were weakly predictive of LMD (C-index 0.643 and 0.684). CONCLUSIONS: In patients with moderate or severe ischemia, clinical and stress testing parameters were weakly predictive of LMD on CTA. For most patients with moderate or severe ischemia, anatomical imaging is needed to rule out LMD. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).
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