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a standardized reporting system has recently been introduced&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> The Coronary Artery Disease - Reporting and Data System &#40;CAD-RADS&#41; classification parallels similar successes in other areas of medicine&#44; notably the BI-RADS classification for breast exams&#44; and provides recommendations for further management&#44; according to the test result&#46; Patients with no coronary artery disease or no significant stenosis &#40;&#62;50&#37;&#41; detected on CCTA should be excluded from further testing&#44; while those with detected stenosis should proceed to ischemia assessment or viability testing and&#47;or invasive coronary angiography &#40;ICA&#41;&#44; if appropriate&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> One of the main advantages of this approach is its emphasis on the need for functional testing before ICA when intermediate and&#47;or severe stenosis is detected on CCTA&#44; in order to reduce false positive referrals and the &#8216;oculo-stenotic reflex&#8217; in the catheterization laboratory&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; an interesting paper by Guerreiro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> describes the post-test management of 200 patients referred for CCTA due to suspected or known coronary artery disease in a Portuguese tertiary center prior to the introduction of the CAD-RADS classification in CCTA reports&#44; comparing post-test management with that proposed under the new system&#46; Interestingly&#44; but not unexpectedly&#44; the results show that in patients with CAD-RADS classifications at the ends of the spectrum&#44; additional cardiac investigation after CCTA was almost always in agreement with the recommendations&#44; but in patients with intermediate scores&#44; ICA prevailed over functional testing&#46; This result reinforces the general perception that too many patients are being directly referred for catheterization after CCTA&#44; and are therefore being excluded from the benefits of functional testing &#40;which could potentially improve subsequent treatment&#41;&#46; Even in patients with more severe stenosis &#40;&#62;70&#37;&#41; &#8211; in whom direct referral for catheterization may be considered under the CAD-RADS classification &#40;and were therefore considered in agreement with the CAD-RADS recommendations in this paper&#41; &#8211; these real-world data reveal the clear preponderance of anatomically-driven paths in patient management after CCTA &#40;with non-invasive testing performed in only 10&#37; of these cases&#41;&#46; It is clear that&#44; as the authors state&#44; not all of these patients were excluded from functional testing&#44; since some may have been tested invasively using fractional flow reserve or instantaneous wave-free ratio measurement&#46; Nevertheless&#44; the under-use of non-invasive functional tests in this population demonstrates that there is room for improvement and should prompt reflection concerning the causes and actions required&#46; As Guerreiro et al&#46; noted&#44; easy access to ICA compared to stress imaging tests may explain a significant part of this referral bias&#46; Therefore&#44; in order to fully benefit from the unprecedented information provided by advanced imaging modalities like CCTA&#44; cardiology departments as we know them must change&#46; For the sake of better patient management&#44; promotion of timely and accurate non-invasive diagnostic approaches &#40;reserving ICA mostly for therapeutic procedures&#41; is essential&#46; Cath-lab-centered departments should give way to balanced and structured units in which multimodality non-invasive and invasive techniques are equally available&#46; Only then can we look forward to the full positive impact on both efficacy and costs of these techniques and the additional value of systematic classification systems like CAD-RADS in clinical practice&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Editorial Comment
Management of patients after computed tomography coronary angiography: Evidence and room for improvement
Tratamento de doentes após angiocoronariografia computorizada: evidência e espaço para aperfeiçoamento
Nuno Bettencourt
Faculdade de Medicina, Universidade do Porto, Porto, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In recent years coronary computed tomography angiography &#40;CCTA&#41; has become the unquestionable gold standard for non-invasive coronary anatomy assessment&#46; Its role in the management of patients with chest pain is gaining importance in the clinical arena and the tendency in recent guidelines is to prefer CCTA as first-line testing over other imaging modalities&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">However&#44; CCTA is a purely anatomical test and one of the main criticisms that have been made of its widespread use is that it may increase unnecessary referrals for cardiac catheterization&#44; another anatomical test&#46; Furthermore&#44; the lack of a unified reporting system may limit the clinical impact of the test on subsequent management&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In order to improve patient management after CCTA&#44; a standardized reporting system has recently been introduced&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> The Coronary Artery Disease - Reporting and Data System &#40;CAD-RADS&#41; classification parallels similar successes in other areas of medicine&#44; notably the BI-RADS classification for breast exams&#44; and provides recommendations for further management&#44; according to the test result&#46; Patients with no coronary artery disease or no significant stenosis &#40;&#62;50&#37;&#41; detected on CCTA should be excluded from further testing&#44; while those with detected stenosis should proceed to ischemia assessment or viability testing and&#47;or invasive coronary angiography &#40;ICA&#41;&#44; if appropriate&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> One of the main advantages of this approach is its emphasis on the need for functional testing before ICA when intermediate and&#47;or severe stenosis is detected on CCTA&#44; in order to reduce false positive referrals and the &#8216;oculo-stenotic reflex&#8217; in the catheterization laboratory&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; an interesting paper by Guerreiro et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> describes the post-test management of 200 patients referred for CCTA due to suspected or known coronary artery disease in a Portuguese tertiary center prior to the introduction of the CAD-RADS classification in CCTA reports&#44; comparing post-test management with that proposed under the new system&#46; Interestingly&#44; but not unexpectedly&#44; the results show that in patients with CAD-RADS classifications at the ends of the spectrum&#44; additional cardiac investigation after CCTA was almost always in agreement with the recommendations&#44; but in patients with intermediate scores&#44; ICA prevailed over functional testing&#46; This result reinforces the general perception that too many patients are being directly referred for catheterization after CCTA&#44; and are therefore being excluded from the benefits of functional testing &#40;which could potentially improve subsequent treatment&#41;&#46; Even in patients with more severe stenosis &#40;&#62;70&#37;&#41; &#8211; in whom direct referral for catheterization may be considered under the CAD-RADS classification &#40;and were therefore considered in agreement with the CAD-RADS recommendations in this paper&#41; &#8211; these real-world data reveal the clear preponderance of anatomically-driven paths in patient management after CCTA &#40;with non-invasive testing performed in only 10&#37; of these cases&#41;&#46; It is clear that&#44; as the authors state&#44; not all of these patients were excluded from functional testing&#44; since some may have been tested invasively using fractional flow reserve or instantaneous wave-free ratio measurement&#46; Nevertheless&#44; the under-use of non-invasive functional tests in this population demonstrates that there is room for improvement and should prompt reflection concerning the causes and actions required&#46; As Guerreiro et al&#46; noted&#44; easy access to ICA compared to stress imaging tests may explain a significant part of this referral bias&#46; Therefore&#44; in order to fully benefit from the unprecedented information provided by advanced imaging modalities like CCTA&#44; cardiology departments as we know them must change&#46; For the sake of better patient management&#44; promotion of timely and accurate non-invasive diagnostic approaches &#40;reserving ICA mostly for therapeutic procedures&#41; is essential&#46; Cath-lab-centered departments should give way to balanced and structured units in which multimodality non-invasive and invasive techniques are equally available&#46; Only then can we look forward to the full positive impact on both efficacy and costs of these techniques and the additional value of systematic classification systems like CAD-RADS in clinical practice&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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ISSN: 08702551
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