Coronary angiography is the gold standard diagnostic
technique, which helps in therapeutic decision making in coronary disease.
Coronary CT angiography is also a valuable aid to assess coronary heart
disease. But, it has not been so widely used as the invasive coronary
angiography.
But, the SYNTAX III REVOLUTION trial has now demonstrated
that the non-invasive coronary CT angiography is non inferior to the invasive
coronary angiography in diagnostic value.
The SYNTAX III Revolution trial for the first time
randomised two separate Heart Teams (in six participating international
centres) and not the patients, to quantify the anatomical complexity by using
the SYNTAX score in patients with known de novo left main or
three-vessel CAD in six participating international centres using information
obtained from either coronary CTA or conventional angiography.
The primary goal was to assess the treatment decision,
whether to decide on percutaneous coronary intervention (PCI), coronary artery
bypass grafting (CABG) or equipoise between CABG and PCI.. The primary endpoint
of this study was agreement between the two heart teams on the
revascularization strategy.
Heart Team A had to make their decision on whether to
perform revascularization with either PCI or surgery using information received
strictly from the non-invasive multislice coronary computed tomography
angiography (MSCT) from a GE Revolution multislice CT scan along with
fractional flow reserve (FFR) CT assessment (HeartFlow).
Heart Team B also needed to make the same decision but
using only conventional angiography.
·
No significant differences in the number of coronary
stenoses > 50%, and SYNTAX score calculated by using coronary CTA and
conventional angiography, were observed (1108 vs 1073 and 33.9 ± 12.0 vs. 30.3
± 12.2, respectively).
·
CABG was recommended in 28% of patients by coronary CTA
and in 26% of patients by invasive coronary angiography.
·
Equipoise CABG or PCI was suggested in 106 patients, with
no difference between CTA and coronary angiography. Overall, the heart teams
agreed on the coronary segments to be revascularized in 81.1% of cases.
FFRCT was available in 868 of the 1108 lesions and
identified no flow-limiting stenosis in 116 lesions in 34% of the patients;
thus, changing the treatment decision in 7% of the patients (the surgical
procedure was changed to a percutaneous approach in 13 patients) and reducing
the proportion of patients with haemodynamically significant three-vessel
disease from 92.3 to 78.8%.
The European Society of Cardiology Guideline recommends
coronary CTA as a class IIa indication in the presence of a low–intermediate
pre-test probability risk of CAD.
These results from the SYNTAX III Revolution trial show
that non-invasive multislice CT scans may well be the future in diagnostic
imaging to assess the extent of coronary disease, whether it is a one-vessel or
multivessel disease, and to guide decision-making accordingly regarding the
revascularization strategy to adopt.
The results of the trial are published in the European
Heart Journal.
Dr KK Aggarwal
Padma
Shri Awardee
President
Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)
Group
Editor-in-Chief IJCP Publications
President
Heart Care Foundation of India
Immediate
Past National President IMA
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