Divergence between observed and guideline-recommended pathways was evident across all CAD-RADS categories, indicating a need for structured implementation of CAD-RADS-guided care pathways.
Abstract
Background
Coronary computed tomography angiography (CCTA) reported with Coronary Artery Disease Reporting and Data System (CAD-RADS) 2.0 is increasingly used in chronic coronary syndromes, but real-world adherence to the recommended downstream pathways is poorly characterized.
Aims
To describe the population referred for CCTA in a Polish tertiary center, the distribution of CAD-RADS 2.0 categories by sex and age, and adherence to guideline-recommended downstream pathways.
Methods
We retrospectively analyzed 10 005 consecutive patients who underwent CCTA between July 1, 2022 and December 31, 2024. Downstream procedures were identified in the National Health Fund registry. A pre-specified multivariable logistic regression model (CAD-RADS category, age, sex) described referral for invasive coronary angiography (ICA); discrimination was quantified as the area under the receiver-operating-characteristic curve (AUC).
Results
Women constituted 57.8% of the cohort and were older than men (mean 66.4 vs. 64.1 years; P < 0.001). The distribution of categories differed by sex (P < 0.001). Among patients with CAD-RADS 0-2, 18.5% underwent at least one additional test. Among patients with CAD-RADS 3, 41.8% proceeded directly to ICA without prior functional testing and 17.7% followed a functional-testing-first pathway. Among patients with CAD-RADS 4-5, 26.0% did not undergo ICA and 17.8% had no further testing. CAD-RADS category dominated referral for ICA (full model AUC 0.886; 95% confidence interval, 0.877-0.894; CAD-RADS alone 0.883; age and sex alone 0.677).
Conclusions
Divergence between observed and guideline-recommended pathways was evident across all CAD-RADS categories, indicating a need for structured implementation of CAD-RADS-guided care pathways.
PURPOSE
While anatomical Coronary Artery Disease Reporting and Data System (CAD-RADS) is widely used for coronary CT angiography (CCTA) reporting, it has limited specificity for predicting lesion-specific ischemia. This study evaluates whether the novel functional CAD-RADS, integrating CT-derived fractional flow reserve (CT-FFR), provides superior 5-year prognostic value in patients with stable coronary artery disease (CAD).
METHODS
A single-center prospective cohort study enrolled 1096 participants aged ≥18 years with CAD referred for CCTA with stenosis degrees of 25%-80%. Primary endpoints were major adverse cardiac events (MACE). The appropriateness of management decisions relative to anatomical or functional CAD-RADS recommendations was explored. Statistical analyses included Kaplan-Meier estimates, Cox proportional hazards models, measures of integrated discrimination improvement (IDI) and net reclassification improvement (NRI).
RESULTS
After a median follow-up of 64 months, 158 MACEs occurred. Both functional and anatomical CAD-RADS categories predicted MACE (p < 0.001). Functional CAD-RADS showed a higher C-index (0.780; 95% confidence interval [CI]: 0.764, 0.796) compared to anatomical CAD-RADS (0.723; 95% CI: 0.703, 0.743) for predicting MACE (p=0.035), with improved discrimination (IDI: 0.053 [95% CI: 0.016, 0.110]; p=0.008). The proportion of inappropriate management decisions was lower for functional CAD-RADS (9.9%) than for anatomical CAD-RADS (11.0%, p<0.001). The hazard ratios for MACE when comparing dichotomous appropriate and inappropriate management decisions relative to functional CAD-RADS were 9.544 (95% CI: 5.794, 15.720; p<0.001), and 2.475 (95% CI: 1.369, 4.474); p<0.001) for anatomical CAD-RADS recommendations, corresponding to the number needed to treat of 1.912 (95% CI: 1.605, 2.364), and 5.076 (95% CI: 3.546, 10.204), respectively.
CONCLUSION
Functional CAD-RADS may offer improved predictive power for moderate-term outcomes compared to anatomical CAD-RADS, suggesting potential clinical utility in guiding patient management and informing treatment algorithms for CAD, particularly in patients with intermediate stenosis.
Chun-Xiang Tang, F. Zhou, Hong-Yan Qiao et al.· Journal of the American Coll...· 0 citations
Preliminary findings suggest CSG may serve as a triage tool before CCTA or cardiology referral before coronary computerized tomography angiography referral, and higher sensitivity than resting ECG for detecting coronary plaque is demonstrated.
Rafael A. Guillén-Marmolejos, R. Núñez-Musa, A. Núñez-Selles et al.· Frontiers in Cardiovascular...· 0 citations
BACKGROUND AND AIMS
Coronary computed tomography angiography (CCTA) as first-line diagnostic tool for suspected coronary artery disease (CAD) offers detailed assessment of coronary plaque, yet data on non-calcified components remain limited. This study aims to analyze total coronary plaque burden as well as non-calcified plaque characteristics in an ESC-guideline-selected cohort and to establish age- and sex-specific percentile distributions and benchmark values for quantitative plaque assessment.
METHODS
All patients undergoing CCTA for a clinical indication at a German outpatient institution between July 2017 and June 2020 were included. Plaque analysis using validated semi-automated software was performed on all coronary arteries; plaque burden was measured with differentiation among total, calcified, non-calcified, and low-attenuation components.
RESULTS
Of 5412 patients, coronary plaques were present in 67.1% of patients, with obstructive CAD in 29.3%. For example, the 50th, 75th, and 90th percentile values for total coronary plaque burden were 28.8 mm3, 130.2 mm3, and 302.0 mm3, respectively. Total plaque burden showed strong diagnostic performance for obstructive CAD, with optimal cut-off values of 68.45 mm3 in males (sensitivity 0.89, specificity 0.74) and 21.18 mm3 in females (sensitivity 0.93, specificity 0.77) showing the best discriminatory performance within the present cohort. Within this cohort, plaque burdens below 22.0 mm3 in males and 12.4 mm3 in females were associated with a false-negative rate below 5% for the presence of obstructive CAD.
CONCLUSIONS
This study provides novel insights into the prevalence and distribution of coronary plaque burden in a large outpatient cohort undergoing CCTA according to current ESC guideline recommendations. The presented age- and sex-specific percentile distributions provide benchmark values for quantitative plaque assessment in a real-world CCTA population and may facilitate standardized reporting and future outcome-based investigations of coronary plaque burden and composition.
Philipp Breitbart, C. Liebetrau, Dimitri Grün et al.· Clinical Research in Cardiol...· 0 citations
Invasive coronary angiography (CAG) remains widely used in Norway, with 37% of procedures in 2022 yielding normal findings, indicating potential overuse. A national multidisciplinary task force performed a retrospective registry-based analysis and reviewed the European Society of Cardiology (ESC) guidelines to identify strategies aimed at reducing the utilization of CAG in patients with suspected coronary disease. Significant regional variation in CAG and Coronary Computed Tomography Angiography (CCTA) utilization was observed. Complication rates for CAG in stable patients were low, 0.6%. In patients with low and moderate pre-test probability and suspected Chronic Coronary Syndrome (CCS), CCTA is recommended as a first-line imaging test. Standardization of CCTA protocols and reports, using CAD-RADS 2.0, mandatory CCTA registration in Norwegian Registry of Invasive Cardiology (NORIC), and formal collaboration between radiologists and cardiologists are essential initiatives. The aim is to reduce invasive procedures not resulting in revascularization by 5–10 percentage points nationally.
A. Kristensen, Marit Herder, E. Aune et al.· Research in Health Services...· 0 citations
BACKGROUND
Implementing non-invasive coronary imaging affects the use and distribution of non-obstructive coronary artery disease in coronary angiography (CAG).
AIMS
To identify current trends in CAG findings, the clinical phenotype associated with non-significant lesions and predictors of normal angiogram.
METHODS
The study included 749 235 CAGs recorded in the National Registry of Procedures of Invasive Cardiology database in Poland (456 202 [61%] were performed on men, with a median age of 67 years). Data were collected between 2014 and 2024 from patients with chronic coronary syndromes.
RESULTS
No significant stenosis was found in 49.5% of cases. The frequency of non-obstructive coronary artery disease showed increasing trend (range 32.4%-41.4%), while normal angiograms showed decreasing trend (range 16.4%-9.3%). Multivessel disease (MVD) without left main coronary artery (LMCA) involvement showed decreasing trend (range 23.9%-22.1%) as well as LMCA-only disease (range 0.36%-0.23%). Higher body weight and chronic obstructive pulmonary disease increased the likelihood of normal angiogram. Older age, male sex, diabetes, prior myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting, current smoking, hypertension, kidney disease, and psoriasis reduced it. Risk of periprocedural complications during CAG in group referred to conservative treatment have been increased by single-vessel disease (65%), MVD with/without LMCA stenosis (72%-81%), current smoking (39%), psoriasis (over 3-fold), and kidney disease (48%), while male sex reduced the risk by 34%.
CONCLUSIONS
Non-obstructive atherosclerotic lesions are increasingly recognized. Groups with and without significant stenosis differ in clinical and anthropometric profiles. Body weight and chronic obstructive pulmonary disease predicted conservative management. Current smoking, psoriasis, kidney disease, and MVD increased procedural risk; male sex decreased it.
K. Kaziród-Wolski, Janusz Sielski, Kamil Salwa et al.· Kardiologia polska· 0 citations
BACKGROUND
Computed Tomography-derived Fractional Flow Reserve (FFRct) integrates anatomical and functional information, which is particularly useful for stable coronary artery disease (CAD) patients with at least intermediate stenosis.
OBJECTIVES
We investigated the impact of adding FFRct to the diagnostic pathway of CAD patients with a 50-90% stenosis on Coronary Computed Tomography Angiography (CCTA).
METHODS
FUSION is an investigator-initiated, multicenter, randomized controlled trial involving patients with 50-90% stenosis in ≥1 coronary artery on CCTA. Patients were randomized to FFRct-guided or usual care. The primary endpoint was invasive coronary angiography (ICA) without obstructive CAD at 90 days. Secondary endpoints included ICA without obstructive CAD, major adverse cardiac events (MACE), and costs at 1 year, as well as revascularizations, and quality of life at 90 days and 1 year. ICA use was assessed as a post-hoc exploratory endpoint.
RESULTS
Overall, 528 patients (median age 63 [57-69] years, 59% male) were randomized to FFRct-guided (n=263) or usual care (n=265). At 90 days, the rate of ICA without obstructive CAD was significantly lower in the FFRct group than in the usual care group (18% (48/263) versus 33% (87/265); odds ratio 0.46; 95% confidence interval, 0.31-0.69; P<0.001). ICA rate was 39% (102/263) versus 51% (136/265), respectively (P=0.004). Both differences persisted at 1 year. Revascularization rates were similar: 20% (52/263) versus 20% (53/265) at 1 year, respectively (P=0.948). Quality of life, costs, and MACE did not differ between groups, although the clinical event rates were low.
CONCLUSIONS
Adding FFRct to the diagnostic pathway of patients with a 50-90% stenosis on CCTA reduced the rate of ICA without obstructive CAD at 90 days and 1 year, without differences in revascularizations, quality of life, and costs compared to usual care. Clinical event rates were similar, although low. The rate of overall ICA use, a post-hoc exploratory outcome, was also reduced at 90 days and 1 year.
Simran P. Sharma, Ricardo P. J. Budde, P. Marc van der Zee et al.· Journal of the American Coll...· 0 citations
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