• VERDICT Analysis: Coronary Computed Tomography is ‘Equivalent’ to Invasive Coronary Angiography in NSTEACS Risk Stratification

    Coronary computed tomography angiography (CTA) was as effective as invasive coronary angiography (ICA) for predicting long-term risk in patients with non–ST-segment elevation acute coronary syndrome (NSTEACS), according a 4-year follow-up analysis of the Danish VERDICT trial.

    The results were published online on Monday in the March 2 issue of the Journal of the American College of Cardiology by a team of authors led by Klaus F. Kofoed, MD, DmSc, from the University of Copenhagen, Denmark.

    ICA is the current primary diagnostic pathway used to assess severity and extent of coronary artery disease (CAD) to guide treatment and predict outcomes in patients with NSTEACS, the researchers said.

    However, they highlighted the fact that a routine invasive strategy is associated with an increased risk of bleeding and prolonged hospital stay, adding that it “may not provide long-term benefits to all patients with NSTEACS”.

    CTA is a logistically simple, accurate and low-risk noninvasive test that is primarily used to rule out CAD, they said, but which has proven to have high diagnostic accuracy in ruling out obstructive CAD in patients with NSTEACS in another VERDICT (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography in Patients With Acute Coronary Syndromes) trial analysis.

    Nevertheless, CTA’s effectiveness versus ICA in providing prognostic information has been unknown.

    The researchers, therefore, set out to evaluate whether coronary CTA is equivalent to ICA for risk assessment in patients with NSTEACS in the VERDICT trial, which included patients from nine hospitals in the Copenhagen region randomized to either an acute invasive strategy within 12 hours or to a deferred invasive strategy within 48 to 72 hours. The trial included an observational component prior to ICA in which patients underwent a clinically blinded coronary CTA.

    The primary endpoint was a composite of all-cause death, nonfatal recurrent myocardial infarction, hospital admission for refractory myocardial ischemia, or heart failure.

    The current study included 978 patients in whom coronary CTA and ICA were conducted (with CTA findings remaining blinded through the entire study period). During a median follow-up time of 4.2 years (interquartile range: 2.7 to 5.5 years), the primary endpoint occurred in 21.3% (208) of the patients overall.

    The rate of the primary endpoint was up to 1.7-fold higher in those with obstructive CAD compared to non-obstructive as defined by coronary CTA (hazard ratio [HR]: 1.74; 95% confidence interval [CI]: 1.22 to 2.49; p = 0.002) or by ICA (HR: 1.54; 95% CI: 1.13 to 2.11; p = 0.007).

    For those with high-risk CAD, the primary endpoint rate was 1.5-fold higher than for those with non-high risk CAD as defined by coronary CTA (HR: 1.56; 95% CI: 1.18 to 2.07; p = 0.002), with similar results seen for ICA diagnoses (HR: 1.28; 95% CI: 0.98 to 1.69; p = 0.07).

    Coronary CTA was, therefore, equivalent to ICA for the assessment of long-term risk in patients with NSTEACS in VERDICT, the researchers concluded, adding that CTA could, therefore, provide an alternative to invasive ICA.

    The authors added that randomized trials are now needed to define patterns of CAD identified by CTA in NSTEACS patients.

    The study opens up the possibility of using coronary CTA to risk-stratify patients with NSTEACS and select those who could benefit from invasive coronary angiography, said editorialists led by Michelle C. Williams, MBChB, PhD, from the University of Edinburgh, Scotland, in an accompanying text.


    Kofoed KF, Engstrøm T, Sigvardsen PE, et al. Prognostic Value of Coronary CT Angiography in Patients With Non–ST-Segment Elevation Acute Coronary Syndromes. J Am Coll Cardiol 2021;77:1044-52.

    Williams MC, Dweck MR, Newby DE. Coronary Computed Tomography Angiography to Triage Patients With Non–ST-Segment Elevation Acute Coronary Syndrome. J Am Coll Cardiol 2021;77:1053-6.

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