Predictors of Left Main Coronary Artery Disease in the ISCHEMIA Trial.

BACKGROUND

Detection of ≥50% diameter stenosis left main coronary artery disease (LMD) has prognostic and therapeutic implications. Noninvasive stress imaging or an exercise tolerance test (ETT) are the most common methods to detect obstructive coronary artery disease, though stress test markers of LMD remain ill-defined.

OBJECTIVES

The authors sought to identify markers of LMD as detected on coronary computed tomography angiography (CTA), using clinical and stress testing parameters.

METHODS

This was a post hoc analysis of ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches), including randomized and nonrandomized participants who had locally determined moderate or severe ischemia on nonimaging ETT, stress nuclear myocardial perfusion imaging, or stress echocardiography followed by CTA to exclude LMD. Stress tests were read by core laboratories. Prior coronary artery bypass grafting was an exclusion. In a stepped multivariate model, the authors identified predictors of LMD, first without and then with stress testing parameters.

RESULTS

Among 5,146 participants (mean age 63 years, 74% male), 414 (8%) had LMD. Predictors of LMD were older age (P < 0.001), male sex (P < 0.01), absence of prior myocardial infarction (P < 0.009), transient ischemic dilation of the left ventricle on stress echocardiography (P = 0.05), magnitude of ST-segment depression on ETT (P = 0.004), and peak metabolic equivalents achieved on ETT (P = 0.001). The models were weakly predictive of LMD (C-index 0.643 and 0.684).

CONCLUSIONS

In patients with moderate or severe ischemia, clinical and stress testing parameters were weakly predictive of LMD on CTA. For most patients with moderate or severe ischemia, anatomical imaging is needed to rule out LMD. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

Informations de copyright

Copyright © 2022 American College of Cardiology Foundation. All rights reserved.

Déclaration de conflit d'intérêts

Funding Support and Author Disclosures This project was supported in part by Clinical Translational Science Award Nos. 11UL1 TR001445 and UL1 TR002243 from the National Center for Advancing Translational Sciences, and National Heart, Lung, and Blood Institute grants U01HL105907, U01HL105462, and U01HL105561, and U01HL105565. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Center for Advancing Translational Sciences, the National Heart, Lung, and Blood Institute, the National Institutes of Health, or the Department of Health and Human Services. Medications and/or devices were provided by Abbott Vascular, Medtronic, Abbott Laboratories (formerly St. Jude Medical), Royal Philips NV (formerly Volcano Corporation), Omron Healthcare, Amgen, Arbor Pharmaceuticals, AstraZeneca Pharmaceuticals, Merck Sharp & Dohme Corp, Sunovion Pharmaceuticals, and Espero BioPharma. Arbor Pharmaceuticals and AstraZeneca Pharmaceuticals made financial donations. Drs Senior, Reynolds, Min, Berman, Picard, Chaitman, Shaw, Page, Govindan, Sendon, Peteiro, Wander. Drozdz, Marin-Neto, Selvanayagam, Newman, Thuaire, Christopher, Jang, Kwong, Bangalore, Stone, O’Brien, Boden, Maron, and Hochman have received grants from the National Heart, Lung, and Blood Institute during the conduct of the study. Dr Hochman is principal investigator for the ISCHEMIA trial. Dr Reynolds has received nonfinancial support from Abbott Vascular; has received nonfinancial support from Siemens; and has received nonfinancial support from BioTelemetry, outside the submitted work. Dr Min has received grants from Cleerly Inc, GE Healthcare, and Arineta, outside the submitted work. Dr Berman has received grants from GE, CSMC Heartflow, and Bayer; and receives software royalties from Cedars-Sinai Medical Center outside the submitted work. Dr Chaitman has received personal fees from Merck, NovoNordisk, Lilly, Johnson and Johnson, Daiichi-Sankyo, Imbria, Xylocor, Sanofi, Tricida, and Xylocor outside the submitted work. Dr Sendon has received grants from Bayer, Merck, Pfizer, Menarini, Sanofi, Boehringer Ingelheim, and Amgen; and has received personal fees from Pfizer, Menarini, Sanofi, and Boehringer Ingelheim outside the submitted work. Dr Bangalore has received grants from Abbott Vascular; and has received personal fees from Abbott Vascular, Biotronik, Pfizer, Amgen, and Reata outside the submitted work. Dr Stone has received personal fees from Terumo, Amaranth, Shockwave, Valfix, TherOx, Reva, Vascular Dynamics, Robocath, HeartFlow, Gore, Ablative Solutions, Matrizyme, Miracor, Neovasc, V-wave, Abiomed, Claret, Sirtex, Ancora, Qool Therapeutics, SpectraWave, MAIA Pharmaceuticals, Orchestra Biomed, and Vectorious; and has received fees from Valfix, Ancora, Qool Therapeutics, Cagent, Applied Therapeutics, Biostar family of funds, MedFocus family of funds, SpectraWave, Orchestra Biomed, Aria, and Cardiac Success, outside the submitted work. Dr Boden has received grants from Abbvie, Amarin, and Amgen; and has received personal fees from Amgen, Cleveland Clinic Clinical Coordinating Center, and Janssen, outside the submitted work.