Screening coronary artery disease with computed tomography angiogram should limit normal invasive coronary angiogram, regardless of pretest probability.

BACKGOUND: Performing functional testing (FT) or a computed tomography angiogram (CCTA) before invasive coronary angiogram (ICA) is recommended for coronary artery disease (CAD). We aimed to evaluate, in a real life setting, the rate of strictly normal ICA following a positive noninvasive test result. METHODS: We included all patients who underwent an ICA with a prior positive FT or CCTA. Patients were categorized in 5 subgroups, according to pretest probability (PTP) of having a CAD. Main results of ICA were defined as normal ICA, nonobstructive CAD (non-oCAD), and obstructive CAD (oCAD). RESULTS: For 4,952 patients who underwent ICA following either a positive FT (3276, 66.2%) or CCTA (1676, 33.8%) result, the PTP was (1) low (<15%; n = 968, 19.5%), (2) lower intermediate (15%-35%; n = 1336, 27.0%), (3) higher intermediate (35%-50%; n = 806, 16.3%), (4) high (50%-65%; n = 806, 17.7%), and (5) very high (> 65%; n = 965, 19.5%). ICA showed no CAD (819 patients, 16.5%), non-oCAD (1,193 patients, 24.1%), or oCAD (2940 patients, 59.4%). Without considering the PTP values, CCTA compared to FT showed less frequently normal ICA (7% vs 16.5%), and more frequently CAD (non-oCAD 27.9% vs 22.2%; oCAD 65.1% vs 56.4%) (all P < .0001). When we considered the different PTP values, CCTA always showed lower rates of normal ICA than the FT. In low- and lower intermediate-risk patients, CCTA detected more frequently oCAD compared to FT (P < .001). CONCLUSIONS: CCTA is a better alternative than FT to limit unnecessary ICA regardless of PTP value, without missing abnormal ICA.

[Clinical aspects of acute coronary syndromes]. / Aspects cliniques des syndromes coronariens aigus.

There are two types of acute coronary syndromes : those with or without ST-segment elevation. The former require urgent therapeutic measures to reopen the culprit artery (intravenous thrombolysis or primary percutaneous coronary intervention). For the latter, risk stratification is essential and is based upon clinical and biochemical markers. Among them, recent and repeated anginal attacks, ST-segment modifications on admission electrocardiogram, and increased markers of myonecrosis (particularly increased troponin levels) are strong predictors of untoward outcome. According to the risk profile, the initial management is based upon an invasive strategy with powerful antithrombotic medications and urgent angiography, or upon a non-invasive strategy using stress testing, preferably coupled with myocardial imaging techniques. In all instances, secondary prevention measures are determinant to try and stop the progression of the atherosclerotic disease.