European Heart Journal Advance Access originally published online on April 29, 2008
European Heart Journal 2008 29(11):1473; doi:10.1093/eurheartj/ehn176
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Recommendations or mere prose?
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I read with interest the review by Schroeder et al.1 that summarizes the present state of cardiac computed tomography technology. However, the long list of ‘appropriate clinical indications’ for the use of multi-detector computed tomography (MDCT) reflected in Table 3 under the subheading ‘Clinical implications and recommendations’ is misleading. In the text part, the authors confirm that a superior effectiveness of MDCT compared with other modalities for diagnosing congenital or structural anomalies of the heart has not been demonstrated. However, as far as the detection of coronary artery disease (CAD) is concerned, the evidence supporting the use of MDCT is also low.2
The diagnostic accuracy of MDCT in CAD has thoroughly been tested predominantly in patients who do not need it, i.e. in those at high risk in whom it had already been decided to proceed to conventional coronary angiography (CCA). In these populations, diagnostic performance of the test, at least its negative predictive value, is good.3 It should not be taken for granted that these favourable results apply to unselected or lower risk populations as well.4
Most trials have been focusing on the accuracy of MDCT in imaging coronary arteries, but that is not what our patients are asking for. What they want is their symptoms to be alleviated or their survival to be improved. From a societal perspective, these goals should be achieved at a reasonable cost. The review by Schroeder et al. mentions two studies of cost-effectiveness. Only that by Goldstein et al.5 looks at clinical outcomes and the results are bewildering, though not appreciated as such by Schroeder et al.1 This trial enrolled 197 patients with chest pain, admitted to the emergency department and estimated at low risk for serious future events. Ninety-nine patients were randomized to further testing with MDCT and 98 with myocardial perfusion scintigraphy (MPS). If MDCT or MPS indicated severe CAD, the patient was sent for CCA. If MDCT was inconclusive, patients were sent for MPS and subsequently for CCA if deemed necessary. Patients initially referred to MDCT underwent 30% more radiotoxic procedures than those randomized to MPS, and had an increase in revascularizations without any effect on 6 month outcomes, incorporating death, acute coronary syndrome, re-admissions, or late office visits. MDCT in this trial lowered costs, as far as the decision to the need of CCA was concerned. Downstream cost-effectiveness data related to the increased number of revascularizations and unaltered patient outcomes were not accounted for.
The recommendations formulated in this review are inappropriate because they lack robust scientific foundation. Paraphrasing Shaughnessy and Slawson,6 this is mere PROSE, i.e. Prescriptive Recommendations, based On Substandard Evidence.
References
- Schroeder S, Achenbach S, Bengel F, Burgstahler C, Cademartiri F, de Feyter P, George R, Kaufmann P, Kopp AF, Knuuti J, Ropers D, Schuijf J, Tops LF, Bax JJ. Cardiac computed tomography: indications, applications, limitations, and training requirements: report of a Writing Group deployed by the Working Group Nuclear Cardiology and Cardiac CT of the European Society of Cardiology and the European Council of Nuclear Cardiology. Eur Heart J (2008) 29:531–556.
[Abstract/Free Full Text] - Hamon M, Biondi-Zoccai GGL, Malagutti P, Agostoni P, Morello R, Valgimigli M, Hamon M. Diagnostic performance of multislice spiral computed tomography of coronary arteries as compared with conventional invasive coronary angiography: a meta-analysis. J Am Coll Cardiol (2006) 48:1896–1910.
[Abstract/Free Full Text] - Abdulla J, Abildstrom SZ, Gotzsche O, Christensen E, Kober L, Torp-Pedersen C. 64-Multislice detector computed tomography coronary angiography as potential alternative to conventional coronary angiography: a systematic review and meta-analysis. Eur Heart J (2007) 28:3042–3050.
[Abstract/Free Full Text] - Di Carli MF, Hachamovitch R. New technology for noninvasive evaluation of coronary artery disease. Circulation (2007) 115:1464–1480.
[Free Full Text] - Goldstein JA, Gallagher MJ, O'Neill WW, Ross MA, O'Neil BJ, Raff GL. A randomized controlled trial of multi-slice coronary computed tomography for evaluation of acute chest pain. J Am Coll Cardiol (2007) 49:863–871.
[Abstract/Free Full Text] - Shaughnessy AF, Slawson DC. What happened to the valid POEMs? A survey of review articles on the treatment of type 2 diabetes. BMJ (Clin Res Ed) (2003) 327:266.
[Abstract/Free Full Text]
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