Prevalence and predictors of nonobstructive coronary artery disease identified with coronary angiography in contemporary clinical practice

doi:10.1016/j.ahj.2014.03.001

American Heart Journal

Volume 167, Issue 6, June 2014, Pages 846-852.e2

https://doi.org/10.1016/j.ahj.2014.03.001 Get rights and content

Background

Guidelines recommend noninvasive tests (NITs) to risk stratify and identify patients with higher likelihood of coronary artery disease (CAD) prior to elective coronary angiography. However, a high percentage of patients are found to have nonobstructive CAD. We aimed to understand the relationship between patient characteristics, NIT findings, and the likelihood of nonobstructive CAD.

Methods

Patients undergoing elective catheterization without history of CAD were identified from 1,128 hospitals in National Cardiovascular Data Registry's CathPCI Registry between July 2009 and December 2011. Noninvasive tests included stress electrocardiogram, stress echocardiogram, stress radionuclide, stress cardiac magnetic resonance, and computed tomographic angiography. Patient demographics, risk factors, symptoms, and NIT results were correlated with the presence of nonobstructive CAD, defined as all native coronary stenoses <50%.

Results

Of 661,063 patients undergoing elective angiography, 386,003 (58.4%) had nonobstructive CAD. Preprocedure NIT was performed in 64% of patients; 51.9% were reported to be abnormal, but only 9% had high-risk findings. Independent factors associated with nonobstructive CAD were younger age, female sex, atypical chest pain, and a low-risk NIT. Patients with high-risk findings on NIT were more likely to have obstructive CAD (adjusted odds ratio 3.03 [2.86-3.22]). Noninvasive test findings had minimal incremental value beyond clinical factors for predicting obstructive disease (C index = 0.75 for clinical factors vs 0.74 for NIT findings).

Conclusion

In current practice, about two-thirds of patients undergo NIT prior to elective cardiac catheterization, yet most patients have nonobstructive CAD. The weak correlation between most NIT results and the likelihood of obstructive CAD provides further impetus for improving preangiography assessment of likelihood of disease.

Section snippets

Data sources

Data from the CathPCI Registry were analyzed for this manuscript. CathPCI Registry is an initiative of the American College of Cardiology Foundation and The Society for Cardiovascular Angiography and Interventions and has been previously described.7, 8 The NCDR CathPCI Registry is a national registry of clinical data and in-hospital outcomes associated with diagnostic cardiac catheterization and percutaneous coronary intervention from more than 1,300 US hospitals. Data elements that include

Prevalence of nonobstructive CAD and baseline characteristics

Nonobstructive CAD (all stenoses <50%) was identified in 58.4% of patients. Of note, 18.3% of patients had evidence of moderate atherosclerosis defined by stenoses between 20% and 49%, whereas 40.1% of patients had minimal or no stenosis (defined by all stenoses <20%). Table I provides baseline characteristics for the study population and for the cohorts with and without obstructive CAD; all comparisons of baseline variables between the 2 cohorts found statistically important differences.

Discussion

The current analysis demonstrates that in a national sample of patients referred for elective coronary angiography, most patients (58%) are found to have nonobstructive CAD. Noninvasive test was used in 64% of patients before referral. Patients with low-risk and intermediate-risk NIT findings were less likely to have obstructive CAD than all others, including patients with no testing before angiography, but obstructive coronary disease was found more often than nonobstructive disease only in

Conclusions

In current clinical practice, most patients undergoing elective invasive angiography have nonobstructive CAD. The diagnostic yield of coronary angiography for obstructive CAD was found to be low, less than 50%, and unchanging from 2009 to 2011. Women and younger patients were more likely to have nonobstructive CAD. Despite guideline recommendations, only two-thirds of patients have an NIT prior to catheterization. This may be, in part, due to the poor performance of NITs in clinical practice,

Disclosures

Funding: This project was sponsored by the Agency for Healthcare Research and Quality, US Department of Health and Human Services, Rockville, MD, as part of the Cardiovascular Consortium and funded under contract number HHSA290201000007I—Task Order 2, as part of the Research Consortia for Comparative Effectiveness Studies in Cardiovascular Disease. The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for

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: Deepak L. Bhatt, MD, MPH served as guest editor for this article.

^d: D. Dai was responsible for all data analysis.

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Clinical InvestigationCoronary Artery DiseasePrevalence and predictors of nonobstructive coronary artery disease identified with coronary angiography in contemporary clinical practice

Background

Methods

Results

Conclusion

Section snippets

Data sources

Prevalence of nonobstructive CAD and baseline characteristics

Discussion

Conclusions

Disclosures

J Am Coll Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

Low diagnostic yield of elective coronary angiography

N Engl J Med

Frequency of stress testing to document ischemia prior to elective percutaneous coronary intervention

JAMA

Hospital variability in the rate of finding obstructive coronary artery disease at elective, diagnostic coronary angiography

J Am Coll Cardiol

The American College of Cardiology National Database: progress and challenges. American College of Cardiology Database Committee

J Am Coll Cardiol

Clinical Investigation
Coronary Artery Disease
Prevalence and predictors of nonobstructive coronary artery disease identified with coronary angiography in contemporary clinical practice