10 Among 20,241 symptomatic patients from the Western Denmark Heart Registry, the authors concluded that treatment decisions based on objective measures of CAD burden can achieve a more personalized and effective approach to ASCVD risk reduction after initial CCTA evaluation. studied the risk prediction of CAD severity, as measured by diagnostic CCTA, and then modeled the potential influence of this information on the benefit of lipid-lowering therapies. In the recent issue of JACC: Cardiovascular Imaging, Mortensen et al. 7 This further reinforced the notion first arising from emergency department trials of CCTA, including ROMICAT 8 and ACRIN PA, 9 then with PROMISE and SCOT-HEART, that CCTA could also serve as an important tool for potentially directing invasive versus noninvasive management of ASCVD.Ĭoronary Artery Disease Severity as a Treatment Guide More recently, in the ISCHEMIA trial, CCTA was also used to detect significant left main CAD, to identify possible surgical candidates who were excluded from randomization to invasive (angiography and revascularization) versus medical treatment. 6 After identifying both obstructive and nonobstructive CAD in symptomatic patients on CCTA, the early implementation of aggressive preventive strategies including lipid-lowering, anti-hypertensive, and anti-anginal therapies resulted in improvement in clinical outcomes. It was not until 2018, when SCOT-HEART Investigators demonstrated that CCTA for evaluation of individuals with stable chest pain was associated with a lower rate of death from coronary heart disease or nonfatal myocardial infarction compared to standard of care, that the use of CCTA was routinely adopted for outpatient evaluation in individuals with stable chest pain and no known CAD. In this context, CCTA and functional testing can both be considered for the noninvasive evaluation of CAD. 5 However, since CCTA is better able to detect nonobstructive CAD, the discriminatory ability of CCTA in predicting future mid-term ASCVD events bests functional testing. exercise electrocardiogram, exercise imaging, pharmacologic imaging) have similar economic, safety, and clinical-based outcomes. 4 The PROMISE trial first demonstrated that in a real-world, low-to-intermediate risk patient population referred for noninvasive testing for CAD, both CCTA and functional testing (i.e. 3ĬCTA in the Evaluation and Management of ASCVD in Symptomatic IndividualsĬoronary computed tomography angiography (CCTA) has emerged as an important tool in the evaluation of CAD in symptomatic individuals without high risk features in the United States and Europe. Despite these differences, the goal of both guidelines is to match ASCVD risk with the appropriate level of preventive efforts. While the AHA/ACC/MS guideline emphasizes primary and secondary prevention based on the presence of a prior ASCVD event to guide the percent LDL-C reduction achieved with lipid-lowering therapies, the ESC/EAS guideline prioritizes LDL-C goals using subgroups based on individual estimated risk and the presence of high-risk clinical conditions, including subclinical coronary artery disease (CAD) on imaging tests. There are, however, clinically meaningful differences in their approach. Both guidelines aim to reduce ASCVD risk with aggressive lifestyle modifications and by lowering low-density lipoprotein cholesterol (LDL-C) levels with statin and non-statin add-on therapies when indicated. In the United States and Europe, atherosclerotic cardiovascular disease (ASCVD) risk management is based on recommendations from the 2018 American Heart Association (AHA)/American College of Cardiology (ACC)/Multisociety (MS) guideline on the Management of Blood Cholesterol European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) Dyslipidemia guideline, 2 respectively. Building off of SCOT-HEART, this paper provides additional real-world data and modeling estimates on the beneficial effects of aggressively treating symptomatic patients with meaningful CAD on CCTA.Although the approach to primary and secondary prevention of ASCVD differs somewhat between American and European guidelines, there is a clear agreement that LDL-C lowering leads to significant improvement in ASCVD outcomes for symptomatic patients with obstructive and nonobstructive CAD on CCTA.Cardiovascular imaging, including CAC in asymptomatic and CCTA in symptomatic patients, can better identify individuals at increased risk for ASCVD and lead to earlier initiation of aggressive preventive pharmacotherapies according to the burden of disease and ASCVD risk.
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