Original title: All-cause mortality benefit of coronary revascularization vs. medical therapy in patients without known coronary artery disease undergoing coronary computed tomographic angiography: results from CONFIRM (Coronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter Registry) Reference: James K Min et al. European Heart Journal (2012) 33, 3088–3097 doi:10.1093/eurheartj/ehs315.

Several large studies have shown revascularization reduces mortality in stable patients with high risk CAD based on conventional angiography. The goal of this study was to determine the impact in mortality rate of revascularization vs. medical therapy of patients with coronary disease based on CT. 

This observational study included 15223 patients without known coronary condition undergoing multi-slice coronary CT (≥ 64 detectors), divided in high risk (two-vessel CAD with proximal left anterior descending artery involvement, three-vessel CAD, and left main CAD) and low risk CAD. To identify revascularization or medical therapy predictors, they created a score developed by logistic regression. The primary end point was all-cause mortality. 

Revascularization rate was different depending on severity, from 3.8% for non-high-risk CAD to 51.2% high-risk CAD (p<0.01). 82.8% of revascularized patients were treated with angioplasty. Follow up median was 2.1 years (interquartile range 1.4-3.3 years).

After adjusting confounding factors, a reduction in all-cause mortality rates was observed in revascularized patients with high risk CAD, compared to those that received medical therapy (2.28% vs. 5.34% respectively p=0.0075). In low risk CAD patients no differences were observed (2.06% vs. 0.97% p=0.138).

Conclusion 

In patients with no previous history of CAD classified as high risk CAD patients based on multi-slice CT, revascularization reduced all-cause mortality rate.

Editorial Comment:

As an observation study, all outcomes produce more hypotheses that require further randomized studies. On the other hand, CTs are competing with functional studies as screening techniques and this study provides us with the tools to decide when to proceed with coronary angiography and revascularization.

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