High-quality, noninvasive testing may safely diagnose CAD for patients with obesity
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Key takeaways:
- High-quality, noninvasive imaging may safely diagnose CAD for patients with obesity.
- Event rates at 1 year were similar among patients with obesity vs. without, as was secondary testing.
High-quality CT and stress testing should be able to effectively and safely diagnose patients with stable chest pain and suspected CAD, regardless of BMI, while improving clinical efficiency, researchers reported.
A subanalysis of the PRECISE trail was presented at the Scientific Meeting of the Society of Cardiovascular Computed Tomography and simultaneously published in the Journal of Cardiovascular Computed Tomography.
“There are challenges when we are imaging, whether it’s with CT or with stress testing ... with the image quality for patients with high BMI. Traditionally, there have been reports of patients with high BMI not being imaged appropriately, leading to an increase in secondary testing, higher uncertainty of the diagnostic physicians to actually call the results, as well as an increased number of high negative results when using invasive coronary angiography,” Maros Ferencik, MD, PhD, assistant professor of medicine in the division of cardiovascular medicine at Oregon Health & Science University, told Healio. “In clinical practice, with today’s modern scanners, which have the ability to optimize images, provide iterative reconstructions and increase the imaging parameters, therefore impacting image quality, we can manage patients with BMIs that are 35 kg/m2, 40 kg/m2 or higher.
“The similar is true with stress testing,” he said. “Stress echocardiography with contrast or modern [single-photon emission CT] scanners can handle these more difficult patients more easily. This was the motivation to analyze the technology more formally.”
For the PRECISE trial, 2,103 stable, symptomatic patients with suspected CAD and no CAD test within 1 year were randomly assigned to precision or usual testing.
The precision strategy involved quantitative risk stratification, deferred testing and coronary CT angiography with selective noninvasive CT-derived fractional flow reserve (HeartFlow).
As Healio previously reported, the precision strategy conferred a 70% reduction in death, MI or catheterization without obstructive CAD at 1 year compared with usual testing.
For the present subanalysis, Ferencik and colleagues assessed whether there were any differences in testing results and outcomes between participants with obesity and without obesity in the PRECISE trial.The primary outcome was the composite of clinical efficiency — defined as invasive catheterization without obstructive CAD — and safety — defined as death or nonfatal MI.
Obesity was defined as BMI more than 30 kg/m2 and 868 participants were categorized as such. Overall, 1,102 were classified as nonobese.
During a median follow-up of 11.8 months, the researchers reported similar increases in clinical efficiency for patients with obesity compared with those without obesity. This finding was primarily driven by significant reductions in invasive coronary angiography without obstructive CAD, which occurred in approximately 10% of the usual care arm compared with less than 3% of the precision strategy arm and in comparable proportions of patients with and without obesity.
In addition, the rate of death or nonfatal MI was similar between patients with obesity compared with patients without obesity (adjusted HR = 0.98; 95% CI, 0.7-1.37; win ratio = 1.03; 95% CI, 0.53-2.03).
The rate of secondary testing was similar between precision and usual care strategies, regardless of patient BMI.
“The data tell us that both new stress testing and CT are feasible for obese patients. Based on the local experience and expertise in concordance with the most recent [American Heart Association]/[American College of Cardiology] Joint Committee on Clinical Practice Guidelines, we can choose either test,” Ferencik told Healio. “Of course, there is a component of the overall PRECISE strategy that shows that with CT testing, in the right setting of patients, we can decrease the yield of invasive coronary angiography. We can decrease the number of patients that go to the cath lab and have nonobstructive coronary disease, therefore improving the outcomes of our patients. This confirms that use of coronary CTA first, in the right hands, can be an option for many of our patients.”
For more information:
Maros Ferencik, MD, can be reached at 15700 SW Greystone Court, Second Floor, Beaverton, OR 97006.
References:
- Ferencik M, et al. J Cardiovasc Comput Tomogr. 2024;doi:10.1016/j.jcct.2024.05.087.
- SCCT 2024: HeartFlow to present new data on coronary artery disease management with coronary computed tomography angiography. https://www.heartflow.com/newsroom/scct-2024-heartflow/. Published July 16, 2024. Accessed July 31, 2024.
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Ferencik M, et al. Poster session 8 – CT in non-acute chest pain. Presented at: Scientific Meeting of the Society of Cardiovascular Computed Tomography; July 18-21, 2024; Washington, D.C.
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