Korean Circulation Journal

The Korean Society of Cardiology (대한심장학회)
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Nationwide Trends of Gatekeeper to Invasive Coronary Angiography in Suspected Coronary Artery Disease

  • Min Jae Cha (Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine) ;
  • William D Kim (Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Yonsei University Health System) ;
  • Hoyoun Won (Division of Cardiology, Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine) ;
  • Jaeeun Joo (Data Science Team, Hanmi Pharm. Co., Ltd) ;
  • Hasung Kim (Data Science Team, Hanmi Pharm. Co., Ltd) ;
  • In-Cheol Kim (Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine) ;
  • Jin Young Kim (Department of Radiology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine) ;
  • Seonhwa Lee (Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine) ;
  • Iksung Cho (Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Yonsei University Health System)
  • Received : 2022.04.08
  • Accepted : 2022.08.16
  • Published : 2022.11.01
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Abstract

Background and Objectives: Real-world trends in the utility and type of gatekeeping studies in invasive coronary angiography (ICA) requires further investigation. Methods: We identified outpatients who underwent noninvasive cardiac tests or directly ICA for suspected coronary artery disease (CAD) from the nationwide Korea Health Insurance Review and Assessment Service-National Patient Sample database between 2012 and 2018. Results: Among 71,401 patients, the percentage of patients who were evaluated for suspected CAD was 34.7% for treadmill test (TMT), 4.2% for single-photon emission computed tomography (SPECT), 24.2% for coronary computed tomography angiography (CCTA), 1.6% for multiple gatekeepers, and 32.3% for directly ICA without noninvasive studies. The proportion of CCTA as a gatekeeper showed linear increase, (18.6% in 2012 and 28.8% in 2018; p<0.001), while those of TMT, SPECT, and direct ICA have decreased (p<0.001, p=0.03, and p<0.001, respectively). The overall incidence of downstream ICA after gatekeeper was 13.8% (6,662/48,346), and SPECT showed higher ICA rate in pairwise comparison with TMT and CCTA (p<0.001). Patients who performed gatekeepers before ICA showed higher rate of subsequent PCI (34.7% vs. 32.3%; p<0.001) and CABG (3.5% vs. 1.0%; p<0.001), compared to those who directly underwent ICA, and CCTA was associated with higher revascularization rate after ICA in pairwise comparison with TMT and SPECT (p<0.001). Conclusions: Nationwide database demonstrated that CCTA is utilized increasingly as a gatekeeper for ICA and is associated with high revascularization rate after ICA in outpatients with suspected CAD.

Keywords

Acknowledgement

The authors thank Medical Illustration & Design, part of the Medical Research Support Services of Yonsei University College of Medicine, for all artistic support related to this work.

References

  1. Hoorweg BB, Willemsen RT, Cleef LE, et al. Frequency of chest pain in primary care, diagnostic tests performed and final diagnoses. Heart 2017;103:1727-32. https://doi.org/10.1136/heartjnl-2016-310905
  2. Roifman I, Sivaswamy A, Chu A, et al. Clinical effectiveness of cardiac noninvasive diagnostic testing in outpatients evaluated for stable coronary artery disease. J Am Heart Assoc 2020;9:e015724.
  3. Virani SS, Alonso A, Benjamin EJ, et al. Heart disease and stroke statistics-2020 update: a report from the American Heart Association. Circulation 2020;141:e139-596. https://doi.org/10.1161/CIR.0000000000000746
  4. Task Force Members, Montalescot G, Sechtem U, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J 2013;34:2949-3003. https://doi.org/10.1093/eurheartj/eht296
  5. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2012;60:e44-164. https://doi.org/10.1016/j.jacc.2012.07.013
  6. Wolk MJ, Bailey SR, Doherty JU, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American college of cardiology foundation appropriate use criteria task force, American heart association, American society of echocardiography, American society of nuclear cardiology, heart failure society of America, heart rhythm society, society for cardiovascular angiography and interventions, society of cardiovascular computed tomography, society for cardiovascular magnetic resonance, and society of thoracic surgeons. J Am Coll Cardiol 2014;63:380-406. https://doi.org/10.1016/j.jacc.2013.11.009
  7. Keyhani S, Falk R, Bishop T, Howell E, Korenstein D. The relationship between geographic variations and overuse of healthcare services: a systematic review. Med Care 2012;50:257-61. https://doi.org/10.1097/MLR.0b013e3182422b0f
  8. Chinnaiyan KM, Raff GL, Goraya T, et al. Coronary computed tomography angiography after stress testing: results from a multicenter, statewide registry, ACIC (Advanced Cardiovascular Imaging Consortium). J Am Coll Cardiol 2012;59:688-95. https://doi.org/10.1016/j.jacc.2011.10.886
  9. Patel MR, Peterson ED, Dai D, et al. Low diagnostic yield of elective coronary angiography. N Engl J Med 2010;362:886-95. https://doi.org/10.1056/NEJMoa0907272
  10. Marwick TH, Cho I, O Hartaigh B, Min JK. Finding the gatekeeper to the cardiac catheterization laboratory: coronary CT angiography or stress testing? J Am Coll Cardiol 2015;65:2747-56. https://doi.org/10.1016/j.jacc.2015.04.060
  11. Chang HJ, Lin FY, Gebow D, et al. Selective referral using CCTA versus direct referral for individuals referred to invasive coronary angiography for suspected CAD: a randomized, controlled, open-label trial. JACC Cardiovasc Imaging 2019;12:1303-12. https://doi.org/10.1016/j.jcmg.2018.09.018
  12. SCOT-HEART Investigators, Newby DE, Adamson PD, et al. Coronary CT angiography and 5-year risk of myocardial infarction. N Engl J Med 2018;379:924-33. https://doi.org/10.1056/NEJMoa1805971
  13. Douglas PS, Hoffmann U, Patel MR, et al. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med 2015;372:1291-300. https://doi.org/10.1056/NEJMoa1415516
  14. Quan H, Sundararajan V, Halfon P, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 2005;43:1130-9. https://doi.org/10.1097/01.mlr.0000182534.19832.83
  15. Kim L, Kim JA, Kim S. A guide for the utilization of health insurance review and assessment service national patient samples. Epidemiol Health 2014;36:e2014008.
  16. Reeves RA, Halpern EJ, Rao VM. Cardiac imaging trends from 2010 to 2019 in the Medicare population. Radiol Cardiothorac Imaging 2021;3:e210156.
  17. Morris JR, Bellolio MF, Sangaralingham LR, et al. Comparative trends and downstream outcomes of coronary computed tomography angiography and cardiac stress testing in emergency department patients with chest pain: an administrative claims analysis. Acad Emerg Med 2016;23:1022-30. https://doi.org/10.1111/acem.13005
  18. Levin DC, Parker L, Halpern EJ, Rao VM. Coronary CT angiography: use in patients with chest pain presenting to emergency departments. AJR Am J Roentgenol 2018;210:816-20. https://doi.org/10.2214/AJR.17.18740
  19. Budoff MJ, Dowe D, Jollis JG, et al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol 2008;52:1724-32. https://doi.org/10.1016/j.jacc.2008.07.031
  20. Dharampal AS, Papadopoulou SL, Rossi A, et al. Diagnostic performance of computed tomography coronary angiography to detect and exclude left main and/or three-vessel coronary artery disease. Eur Radiol 2013;23:2934-43. https://doi.org/10.1007/s00330-013-2935-6
  21. Dewey M, Rief M, Martus P, et al. Evaluation of computed tomography in patients with atypical angina or chest pain clinically referred for invasive coronary angiography: randomised controlled trial. BMJ 2016;355:i5441.
  22. Nielsen LH, Markenvard J, Jensen JM, Mickley H, Ovrehus KA, Norgaard BL. Frontline diagnostic evaluation of patients suspected of angina by coronary computed tomography reduces downstream resource utilization when compared to conventional ischemia testing. Int J Cardiovasc Imaging 2011;27:813-23. https://doi.org/10.1007/s10554-010-9737-6
  23. Reynolds HR, Shaw LJ, Min JK, et al. Outcomes in the ISCHEMIA trial based on coronary artery disease and ischemia severity. Circulation 2021;144:1024-38. https://doi.org/10.1161/CIRCULATIONAHA.120.049755
  24. Ferencik M, Mayrhofer T, Bittner DO, et al. Use of high-risk coronary atherosclerotic plaque detection for risk stratification of patients with stable chest pain: a secondary analysis of the PROMISE randomized clinical trial. JAMA Cardiol 2018;3:144-52. https://doi.org/10.1001/jamacardio.2017.4973
  25. Xu J, Cai F, Geng C, Wang Z, Tang X. Diagnostic performance of CMR, SPECT, and PET imaging for the identification of coronary artery disease: a meta-analysis. Front Cardiovasc Med 2021;8:621389.
  26. Takx RA, Blomberg BA, El Aidi H, et al. Diagnostic accuracy of stress myocardial perfusion imaging compared to invasive coronary angiography with fractional flow reserve meta-analysis. Circ Cardiovasc Imaging 2015;8:e002666.