CT Angiography Followed by Invasive Angiography in Patients With Moderate or Severe Ischemia-Insights From the ISCHEMIA Trial

G. B.John Mancini, Jonathan Leipsic, Matthew J. Budoff, Cameron J. Hague, James K. Min, Susanna R. Stevens, Harmony R. Reynolds, Sean M. O'Brien, Leslee J. Shaw, Cholenahally N. Manjunath, Kreton Mavromatis, Marcin Demkow, Jose Luis Lopez-Sendon, Alexander M. Chernavskiy, Gilbert Gosselin, Herwig Schuchlenz, Gerard P. Devlin, Anoop Chauhan, Sripal Bangalore, Judith S. HochmanDavid J. Maron

Research output: Contribution to journalArticlepeer-review

42 Scopus citations


Objectives: This study aimed to examine the concordance of coronary computed tomographic angiography (CCTA) assessment of coronary anatomy and invasive coronary angiography (ICA) as the reference standard in patients enrolled in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches). Background: Performance of CCTA compared with ICA has not been assessed in patients with very high burdens of stress-induced ischemia and a high likelihood of anatomically significant coronary artery disease (CAD). A blinded CCTA was performed after enrollment to exclude patients with left main (LM) disease or no obstructive CAD before randomization to an initial conservative or invasive strategy, the latter guided by ICA and optimal revascularization. Methods: Rates of concordance were calculated on a per-patient basis in patients randomized to the invasive strategy. Anatomic significance was defined as ≥50% diameter stenosis (DS) for both modalities. Sensitivity analyses using a threshold of ≥70% DS for CCTA or considering only CCTA images of good-to-excellent quality were performed. Results: In 1,728 patients identified by CCTA as having no LM disease ≥50% and at least single-vessel CAD, ICA confirmed 97.1% without LM disease ≥50%, 92.2% with at least single-vessel CAD and no LM disease ≥50%, and only 4.9% without anatomically significant CAD. Results using a ≥70% DS threshold or only CCTA of good-to-excellent quality showed similar overall performance. Conclusions: CCTA before randomization in ISCHEMIA demonstrated high concordance with subsequent ICA for identification of patients with angiographically significant disease without LM disease.

Original languageEnglish
Pages (from-to)1384-1393
Number of pages10
JournalJACC: Cardiovascular Imaging
Issue number7
StatePublished - Jul 2021
Externally publishedYes


  • cardiac catheterization
  • cardiac computed tomographic angiography
  • invasive coronary angiography
  • ischemia
  • left main coronary artery disease


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