Impact of Coronary Computed Tomography Angiography Findings on Initiation of Cardioprotective Medications
Authors: Anna Marie Chang, Harold I. Litt, Bradley S. Snyder, Constantine Gatsonis, Erin M. Greco, Chadwick D. Miller, Harjit Singh, Katie J. O’Conor, Judd E. Hollander
Journal: Circulation (2017)

HomeCirculationVol. 136, No. 22Impact of Coronary Computed Tomography Angiography Findings on Initiation of Cardioprotective Medications Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBImpact of Coronary Computed Tomography Angiography Findings on Initiation of Cardioprotective Medications Anna Marie Chang, MD, MSCE, Harold I. Litt, MD, PhD, Bradley S. Snyder, MS, Constantine Gatsonis, PhD, Erin M. Greco, MS, Chadwick D. Miller, MD, MS, Harjit Singh, MD, Katie J. O'Conor, BS and Judd E. Hollander, MD Anna Marie ChangAnna Marie Chang Department of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (A.M.C., J.EH.). , Harold I. LittHarold I. Litt Department of Radiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia (H.I.L.). , Bradley S. SnyderBradley S. Snyder Center for Statistical Sciences (B.S.S., C.G.) , Constantine GatsonisConstantine Gatsonis Center for Statistical Sciences (B.S.S., C.G.) Department of Biostatistics (C.G.) , Erin M. GrecoErin M. Greco Brown University School of Public Health, Providence, RI. Novartis Institutes for BioMedical Research, Cambridge, MA (E.M.G.). , Chadwick D. MillerChadwick D. Miller Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (C.D.M.). , Harjit SinghHarjit Singh Department of Radiology, Pennsylvania State Hershey Medical Center (H.S.). , Katie J. O'ConorKatie J. O'Conor Johns Hopkins School of Medicine, Baltimore, MD (K.J.O.). and Judd E. HollanderJudd E. Hollander Department of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (A.M.C., J.EH.). Originally published28 Nov 2017https://doi.org/10.1161/CIRCULATIONAHA.117.029994Circulation. 2017;136:2195–2197Coronary computed tomography angiography (CCTA) has been shown to be highly sensitive for coronary artery disease and acute coronary syndrome.1,2 Few studies have evaluated changes in medical management after CCTA.3,4 Prior studies suggest increases in medical management in the cardiology setting, but none has directly compared CCTA to standard emergency department (ED) care. We sought to determine the difference in initiation of aspirin or statins depending on whether patients were evaluated with CCTA or standard care for acute chest pain.This is a prespecified analysis of a randomized controlled multicenter trial comparing a CCTA-based strategy with traditional rule-out approaches for low- to intermediate-risk patients presenting to the ED with chest pain and possible acute coronary syndrome (ClinicalTrials.gov number: NCT00933400). The full study protocol has been published elsewhere.1 Briefly, patients ≥30 years of age with possible acute coronary syndrome were enrolled and randomized in EDs or observation units at 5 sites. This study was approved by the institutional review boards at participating sites, and all patients provided written informed consent. The degree of maximal stenosis was defined as the maximal stenosis reported from the CCTA scan and was categorized as follows: none, no stenosis; mild, 1% to 49%; moderate, 50% to 69%; and severe, ≥70%.The outcome of this analysis was the initiation of aspirin or statin medications at discharge from the ED or observation unit. Unadjusted and adjusted risk ratios and their corresponding 95% confidence intervals were estimated using Poisson regression with robust error variance.5 Multivariate models were adjusted for age, sex, race, diabetes mellitus, hypertension, hyperlipidemia, family history, smoking, and ED or observation unit discharge, all of which were defined a priori. Statistical computations were done with SAS software (version 9.4, SAS Institute).Among the 1392 enrolled patients, patients taken off-study or who withdrew (n=24), patients randomized to standard care who received a CCTA (n=26), patients randomized to CCTA who either did not receive the examination or had a noncontrast or uninterpretable CCTA (n=146), and patients from either arm who were admitted to the hospital (n=142) were excluded from analysis. The mean age of the 1054 patients was 49 (±9 years), 53% were female, and 57% were black. Baseline variables were balanced between standard care and CCTA. However, when stratified by CCTA results, patients with moderate to severe stenosis were older, were male, and had higher rates of cardiac risk factors and medication use before presentation. Patients in the CCTA arm were no more likely than those in the standard care arm to be newly initiated on statins, but they had a slightly lower rate of aspirin initiation (26% versus 33%, P=0.03). However, initiation of these cardioprotective agents was different based on degree of coronary stenosis. Within 1 year, in the standard care group, 33% of patients were initiated on aspirin. In the CCTA arm, overall, 26% received aspirin, including 17% in those without stenosis, 52% with mild stenosis, 71% with moderate stenosis, and 67% with severe stenosis on CCTA. For statin initiation within 1 year, the results were as follows: 10% in standard care versus 11% in the CCTA arm, including 5% without stenosis; 26% with mild stenosis; 60% with moderate stenosis; and 50% with severe stenosis on CCTA.The relative risks of initiating aspirin and statins at discharge, 30 days, and 1 year are shown in the Table. In general, compared with standard care, patients without stenosis were less likely to be initiated on medications, whereas those with stenosis had a higher likelihood of starting medications.Table. Association of CCTA Coronary Stenosis With Initiation of Aspirin and Statin, Compared With Standard CareInitiationCCTA Stenosis CategoryAspirinStatinN* (Initiated/Total)Risk Ratio† (Unadjusted/Adjusted)(95% CI)P ValueN* (Initiated/Total)Risk Ratio† (Unadjusted/Adjusted)(95% CI)P ValueDischargeStandard care (referent group)37/3331.00——8/3281.00——None: no stenosis17/4240.36(0.21−0.63)<0.001‡3/4350.28(0.08−1.06)0.060.60(0.34−1.06)0.083/4350.45(0.12−1.65)0.23Mild: 1% to 49%38/1202.85(1.91−4.26)<0.001‡9/1143.24(1.28−8.19)0.01‡3.54(2.37−5.28)<0.001‡9/1143.54(1.36−9.20)0.01‡Moderate or severe: ≥50%8/184.00(2.20−7.28)<0.001‡2/155.47(1.27−23.55)0.02‡4.58(2.61−8.06)<0.001‡2/155.15(1.14−23.21)0.03‡30 dStandard care (referent group)36/2881.00——12/3101.00——None: no stenosis22/3980.44(0.27−0.74)0.002‡6/4230.37(0.14−0.97)0.04‡0.50(0.29−0.84)0.009‡6/4230.35(0.14−0.86)0.02‡Mild: 1% to 49%11/781.13(0.60−2.11)0.7110/1002.58(1.15−5.80)0.02‡1.02(0.54−1.91)0.9610/1001.64(0.75−3.57)0.22Moderate or severe: ≥50%4/93.56(1.61−7.85)0.002‡2/124.31(1.08−17.14)0.04‡3.19(1.38−7.38)0.007‡2/123.27(0.84−12.77)0.091 yStandard care (referent group)66/2721.00——22/2931.00——None: no stenosis49/3740.54(0.39−0.75)<0.001‡17/3950.57(0.31−1.06)0.080.65(0.46−0.92)0.02‡17/3950.58(0.31−1.06)0.08Mild: 1% to 49%19/711.10(0.71−1.71)0.6617/922.46(1.37−4.43)0.003‡0.97(0.63−1.51)0.9117/921.86(0.98−3.52)0.06Moderate or severe: ≥50%4/91.83(0.86−3.92)0.126/126.66(3.33−13.33)<0.001‡1.55(0.74−3.25)0.246/125.30(2.68−10.46)<0.001‡CCTA indicates coronary computed tomography angiography; and CI, confidence interval.*For the analysis of initiation at discharge, patients already on the medication at presentation were excluded. For the analysis of initiation at 30 days and 1 year, patients already on the medication at presentation, or prescribed the medication at discharge, were excluded. In addition, at 30 days and 1 year, patients with unknown medication status were excluded.†Multivariate models adjusted for age, sex, race, presence of diabetes mellitus, hypertension, hyperlipidemia, family history of coronary artery disease, smoking, and whether the patient was discharged from the ER or an observation unit.‡Statistically significant.In this analysis of data from a randomized controlled trial comparing CCTA to standard care, the risk of patients having statin therapy initiated was not different between groups that received CCTA and those that received standard care (usually stress testing). When stratified by CCTA results, treatment was more likely with increasing severity of stenosis on the CCTA. Conversely, patients with no stenosis on CCTA were less likely to initiate medical treatment than those evaluated by standard care. Increased medical management based on CCTA results have been shown in other studies; however, most of these were based in cardiology clinics. Most recently, the SCOT-HEART trial (Scottish Computed Tomography of the HEART) demonstrated that CCTA changed medication management and was associated with a decrease in myocardial infarction rate at 2 years.3 We now expand on these findings in an ED-based study. Once a patient has ruled out for an acute event, further risk stratification and optimization of therapy should occur. Limitations to our study include the observational nature of medication prescription, but we felt this was the most feasible way to assess physician prescribing habits after CCTA. We do not have other interim health data or laboratory values, and although we have not calculated a 10-year cardiovascular risk score, we adjusted for cardiovascular risk factors that may have impacted physician medication initiation decisions.In conclusion, a CCTA-based strategy in the ED for the evaluation of symptomatic patients with chest pain was associated with an increased likelihood of aspirin and statins being prescribed to patients most likely to benefit from them (those with increasing amounts of coronary artery disease) and a decreased likelihood of initiation in patients least likely to benefit from them (those without coronary artery disease). Future studies need to examine whether the initiation of medications impacts future healthcare utilization and costs and long-term patient outcomes such as lipid control and acute coronary syndrome rates.Anna Marie Chang, MD, MSCEHarold I. Litt, MD, PhDBradley S. Snyder, MSConstantine Gatsonis, PhDErin M. Greco, MSChadwick D. Miller, MD, MSHarjit Singh, MDKatie J. O'Conor, BSJudd E. Hollander, MDSources of FundingThis project is funded, in part, by a grant from the Pennsylvania Department of Health. The department specifically does not take responsibility for any analyses, interpretations, or conclusions. Additional funding was provided by the American College of Radiology Fund for Imaging Innovation. Dr Chang was supported by NHLBI k12HL108974.DisclosuresDrs Chang, Litt, and Miller received support from Siemens. Dr Litt received support from HeartFlow. The other authors report no conflicts of interest.FootnotesCirculation is available at http://circ.ahajournals.org.Correspondence to: Anna Marie Chang, MD, MSCE, Department of Emergency Medicine, Thomas Jefferson University Hospital, 1020 Sansom St, Ste 241, Philadelphia, PA 19107. E-mail [email protected]References1. Litt HI, Gatsonis C, Snyder B, Singh H, Miller CD, Entrikin DW, Leaming JM, Gavin LJ, Pacella CB, Hollander JE. 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Potential for coronary CT angiography to tailor medical therapy beyond preventive guideline-based recommendations: insights from the ROMICAT I trial.J Cardiovasc Comput Tomogr. 2015; 9:193–201. doi: 10.1016/j.jcct.2015.02.006.CrossrefMedlineGoogle Scholar5. Zou G. A modified poisson regression approach to prospective studies with binary data.Am J Epidemiol. 2004; 159:702–706.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Florea V and Cohn J (2020) Disease Prevention in Heart Failure Heart Failure: a Companion to Braunwald's Heart Disease, 10.1016/B978-0-323-60987-6.00035-1, (487-500.e4), . Honigberg M, Lander B, Baliyan V, Jones-O'Connor M, Healy E, Scholtz J, Nagurney J, Hoffmann U, Ghoshhajra B and Natarajan P (2020) Preventive Management of Nonobstructive CAD After Coronary CT Angiography in the Emergency Department, JACC: Cardiovascular Imaging, 10.1016/j.jcmg.2019.04.021, 13:2, (437-448), Online publication date: 1-Feb-2020. Blaha M and Cainzos-Achirica M (2019) Coronary CT Angiography in New-Onset Stable Chest Pain, Journal of the American College of Cardiology, 10.1016/j.jacc.2018.08.2205, 73:8, (903-905), Online publication date: 1-Mar-2019. Gulhane A and Litt H (2019) Acute Coronary and Acute Aortic Syndromes, Radiologic Clinics of North America, 10.1016/j.rcl.2018.08.004, 57:1, (25-44), Online publication date: 1-Jan-2019. Sharma A, Coles A, Sekaran N, Pagidipati N, Lu M, Mark D, Lee K, Al-Khalidi H, Hoffmann U and Douglas P (2019) Stress Testing Versus CT Angiography in Patients With Diabetes and Suspected Coronary Artery Disease, Journal of the American College of Cardiology, 10.1016/j.jacc.2018.11.056, 73:8, (893-902), Online publication date: 1-Mar-2019. Yasuda S, Kaikita K, Ogawa H, Akao M, Ako J, Matoba T, Nakamura M, Miyauchi K, Hagiwara N, Kimura K, Hirayama A and Matsui K (2018) Atrial fibrillation and ischemic events with rivaroxaban in patients with stable coronary artery disease (AFIRE): Protocol for a multicenter, prospective, randomized, open-label, parallel group study, International Journal of Cardiology, 10.1016/j.ijcard.2018.04.131, 265, (108-112), Online publication date: 1-Aug-2018. Heseltine T, Murray S, Ruzsics B and Fisher M (2020) Latest Advances in Cardiac CT, European Cardiology Review, 10.15420/ecr.2019.14.2, 15 November 28, 2017Vol 136, Issue 22 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.117.029994PMID: 29180497 Originally publishedNovember 28, 2017 Keywordsprimary preventionemergency medicinecoronary CT angiographyPDF download Advertisement SubjectsComputerized Tomography (CT)Primary Prevention