Evaluation of the clinical value of CCTA as the preferred screening method in patients with chronic coronary syndrome

Evaluation of the clinical value of CCTA as the preferred screening method in patients with chronic coronary syndrome | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of the clinical value of CCTA as the preferred screening method in patients with chronic coronary syndrome Huan Luo, Wei Zhu, Rui-juan Fan, Li-xiong Duan, Rui Jing This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4597914/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Feb, 2025 Read the published version in BMC Cardiovascular Disorders → Version 1 posted 16 You are reading this latest preprint version Abstract Background: The advantages and disadvantages of direct invasive coronary angiography (ICA) and coronary computed tomographic angiography (CCTA)+ICA were compared in patients with suspected chronic coronary syndrome (CCS) who presented with angina symptoms or who had nonangina chest pain with abnormal electrocardiogram results. Methods: A total of 1200 patients who met the inclusion criteria at TEDA International Cardiovascular Hospital from January 2021 to December 2022 were randomly divided into two groups at a 1:1 ratio: CCTA+ICA strategy (CCTA group) and direct ICA strategy (ICA group). All patients in the CCTA group underwent CCTA examination first. If these results showed positive obstructive coronary artery disease (CAD), then typical angina with coronary artery stenosis ranging from 50% to 70% or vascular segments could not be analysed due to severe calcification, so ICA was further performed for definitive diagnosis, and ICA results were taken as the final diagnosis. All patients in ICA group underwent ICA examination directly. Demographic data, cardiovascular risk factors, biochemical criteria, chest pain classification, coronary vessel lesion severity and drug use in the two groups were compared. All patients were followed for 1 year after discharge to observe major adverse cardiovascular events (MACE). The differences in unnecessary ICA rate, 1-year MACE, allergic reaction to contrast agent and hospitalization cost between the two groups were analysed. Based on the baseline clinical data of patients included in this study, a risk prediction model for obstructive CAD was established by logistic regression. Results: (1) There were 592 patients in the CCTA group and 594 patients in ICA group. The percentage of unnecessary ICA procedures was 7.5% in the CCTA group and 55.2% in ICA group (P< 0.001). (2) Fifty-one patients in the CCTA group were readmitted for severe angina, 4 of whom underwent unplanned percutaneous coronary intervention (PCI). Eight patients in the ICA group were readmitted for severe angina, 2 of whom underwent unplanned PCI. There were no cardiac deaths, nonfatal myocardial infarctions or strokes in either group over 1-year follow-up. There was no statistically significant difference in the rates of MACE-free survival between the two groups (97.0% vs. 98.7%, log-rankc²=1.996, P=0.158). (3) Allergic reaction to cotrast was observed in 28 patients in the CCTA group and 16 in the ICA group (P＝0.190). (4) The median hospitalization cost in the CCTA group was 9194.61 yuan, and that in the ICA group was 10215.67 yuan, a significant difference. (5) Based on the combination of the logistic regression forward selection method and backward elimination method, variables with P<0.05 were selected from the baseline data of patients to predict obstructive CAD, including creatinine, age, physical activity or emotionally induced symptoms, hyperlipidaemia, diabetes and smoking history. The above variables were used to establish a risk prediction model for obstructive CAD. The area under the ROC curve (AUC) of this model was 0.721, indicating good predictive ability. Conclusion: In patients with suspected CCS, including typical angina, atypical angina and nonangina chest pain with abnormal electrocardiogram results, the use of CCTA as a first-line diagnostic test can reduce the unnecessary incidence of ICA and hospitalization costs without increasing the incidence of MACE. A risk prediction model of obstructive CAD was established based on the baseline data of the patients enrolled in this study, providing a clinical basis for the decision to use CCTA or ICA. Patients with a low probability of obstructive CAD can be given priority for CCTA, while patients with a high probability can be given priority for ICA. invasive coronary angiography coronary computed tomographic angiography chronic coronary syndrome obstructive coronary artery disease major adverse cardiovascular events unnecessary ICA rate Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 1. Background Coronary heart disease (CHD) is a dynamic pathological process characterized by the accumulation of epicardial atherosclerotic plaques and changes in circulatory function. It is divided into two categories: acute coronary syndrome (ACS) and chronic coronary syndrome (CCS) [ 1 ] . In clinical practice, the diagnostic and treatment processes of ACS are relatively fixed. According to the symptoms of chest pain, electrocardiogram (ECG) changes and elevated myocardial injury markers, the risk for ACS can be rapidly stratified, and the corresponding diagnosis and treatment process can be formulated [ 2 , 3 ] . The diagnosis of CCS is more difficult because patients with CCS have more atypical symptoms, a longer course of disease, and more different diseases need to be differentiated. The 2019 European Society of Cardiology (ESC) guidelines for the diagnosis and management of CCS recommend coronary computed tomographic angiography (CCTA) as a first-line test for patients with a low or intermediate clinical likelihood of CHD [ 1 ] . The Cardiovascular CT Society 2021 expert consensus recommends CCTA as the first-line test to evaluate patients with or without prior CHD presenting with stable ischaemic symptoms [ 4 ] . However, in the current clinical setting, ICA is still used as the preferred examination for the early diagnosis of CCS patients because ICA is the gold standard for the diagnosis of CHD [ 5 ] . The advantage of ICA over CCTA is that percutaneous coronary intervention (PCI) can be performed at the same time as lesion detection. However, evidence from the United States [ 6 ] and Europe [ 7 ] suggests that ICA is overused; in more than half of the patients who underwent ICA, the coronary vessels showed normal or no more than 50% stenosis. At the same time, ICA can lead to rare but potentially life-threatening complications [ 8 ] . Therefore, ICA is an invasive, expensive, and possibly unnecessary procedure for these patients. CCTA is the most accurate non-invasive test for diagnosing CHD [ 9 ] . Prospective, multicentre studies have demonstrated the diagnostic accuracy of CCTA in patients with suspected but undiagnosed CHD, with sensitivities ranging from 85–99% and specificities ranging from 64–92% [ 10 – 12 ] . The ISCHEMIA study [ 13 ] showed a high degree of agreement between CCTA and ICA in identifying patients with significant coronary stenosis without left main disease. The ICA confirmed that only 4.9% of the 1,593 patients without left main disease with at least a single-vessel disease identified by CCTA had no significant coronary stenosis. Given that the actual prevalence of CHD is lower than expected and that not all patients with ≥ 50% coronary artery stenosis require invasive treatment, two-thirds of those with 50%-70% coronary artery stenosis have no significant functional significance [ 14 ] . Therefore, CCTA is touted as a "safety gatekeeper" for ICA, with the aim of selecting patients for ICA more accurately [ 15 ] . However, in patients with suspected CCS, there is still a lack of studies on the downstream efficacy, safety and cost of using CCTA as the first-line examination to decide whether the patient should undergo ICA. There have been few comparative studies in China. The aim of this study was to investigate whether CCTA can effectively reduce the use of ICA and reduce the cost of diagnosis and treatment in patients with suspected CCS without increasing the incidence of major adverse cardiovascular events (MACE). 2. Methods 2 .1 Research subjects From January 2021 to December 2022, patients with suspected CCS were enrolled in three categories: typical angina pectoris, atypical angina pectoris, and nonangina chest pain with electrocardiogram changes. There are three characteristics of typical AP: 1) contractive discomfort in the anterior chest, neck, shoulder, jaw, or arm; 2) physical activity or emotional excitement; and 3) symptoms that resolve after about 5 minutes of rest or the use of nitrates. Patients with atypical angina pectoris were defined as having two of these three features, and patients with nonangina chest pain were defined as having one or none [1] . Electrocardiographic changes indicate the presence of any one of the following: Q waves, left bundle-branch block, ST-segment abnormality, or T-wave abnormality. The following patients were excluded: A, previous history of CHD; B, ACS, including ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, and unstable angina pectoris; C, typical angina patients with left ventricular ejection fraction < 50%; D, nonsinus rhythm (atrial fibrillation and frequent premature beats, etc.); E, unable to hold breath for 5 seconds; F. refusal or inability to provide informed consent; G, aged less than 30 years; H, renal insufficiency; I, known congenital heart disease. This study met the ethical standards established by our hospital. Informed consent was obtained from all participants or their family members before CCTA or ICA. 2 .2 Methods 2 .2.1 Grouping The enrolled patients were randomly divided into two groups at a ratio of 1:1 by a random number table: (1) CCTA+ICA strategy (CCTA group): CCTA was performed first; if CCTA results showed positive obstructive coronary artery disease (CAD), typical angina with coronary artery stenosis ranging from 50% to 70% or vascular segments could not be analysed due to severe calcification, ICA was further performed for definitive diagnosis. (2) In the ICA group (direct ICA strategy), ICA examination was performed directly. In both tests, obstructive CAD was defined as at least one 50% diameter stenosis in the left main coronary artery or at least one 70% diameter stenosis in other coronary arteries. 2 .2.2 CCTA Patients were scanned with a Siemens dual-source CT (Somatom Definition flash). First, continuous scanning from the root of the autonomic artery to the apex of the heart was performed with a collimation of 24 mm×1.2 mm, a pitch of 1.2 mm, and a slice thickness of 1.5 mm in one respiratory motion at a tube voltage of 120 kV. Then, a high-pressure syringe was used to inject iodine contrast agent and normal saline into the anterior elbow vein at a flow rate of approximately 5 ml/s. The test bolus technique was applied to calculate the delayed trigger scan time, and the area of interest was selected at the aortic root level to monitor CT values. The peak time plus 5 s was taken as the delayed trigger scan time. CCTA analysis was performed independently by readers who were unaware of the results of the clinical data, and discordant results were resolved by at least two readers. The degree of coronary stenosis was analysed by curved planar reconstruction (CPR) and maximum-intensity projection (MIP) of a Siemens image postprocessing workstation. All segments larger than 2 mm in diameter were classified into the following groups: no stenosis, 1% to 49% stenosis, 50% to 70% stenosis, and more than 70% stenosis. 2 .2.3 ICA ICA was performed on patients using standard techniques on a Philips FD20 single-channel X-ray tube fluoroscopy device. We used the standard Judkins method. The coronary arteries were examined in multiple positions; at least 2 positions were selected for each lesion, and 0.2 mg of nitroglycerine was applied to the target vessel if necessary. The luminal diameter stenosis rate, estimated by visual inspection, was equal to 1 − the minimum lumen diameter/mean diameter of the reference segment, multiplied by 100%. The results were determined by consensus among three senior cardiologists qualified for interventional treatment of CHD. 2 .2.4 Indicators of observation Baseline data (including sex, age, hypertension status, diabetes status, hyperlipidaemia status, smoking history, family history of CHD, chest pain classification, electrocardiogram results, etc.), degree of CAD, contrast agent allergy status, medication use and hospitalization costs were compared. 2 .2.5 Primary and secondary clinical endpoints The primary clinical endpoint of the study was nonessential ICA, which was defined as ICA done in patients who were diagnosed as negative for obstructive CAD. The secondary endpoints were (1) MACE, including cardiac death (any death that could not be explained by noncardiac causes), nonfatal myocardial infarction, stroke, readmission for severe angina symptoms, and unplanned revascularization (PCI or CABG was performed according to the patient's condition during the follow-up period); (2) hospitalization expenses; and (3) contrast-induced allergic conditions. 2 .2.6 Therapeutic management Revascularization was planned for patients with ≥50% diameter stenosis in the left main coronary artery or ≥70% diameter stenosis in other epicardial artery segments. Small collateral lesions with a diameter less than 2 mm that were controlled by drugs were treated conservatively with drugs. Regardless of the number of vessels processed at ICA, the number of stents implanted, and the need for a second completion of residual vascular disease treatment, a single PCI was performed. 2 .2.7 Follow-up Patients were followed up by telephone or in the outpatient clinic after discharge. The follow-up time points were 1 month (±1 week), 3 months (±1 week), 6 months (±1 week) and 12 months (±1 week). MACE that occurred during follow-up were recorded. The study procedure is shown in Figure 1. 2 .3 Statistical analysis SPSS 25.0 was used to process and analyse the research data. Normally distributed measurement data are expressed as mean ± standard deviation (x ̅±s). Comparisons between groups were performed by the two-independent-sample t test. The measurement data that did not meet the normal distribution are expressed as median (interquartile range) [M (P25, P75)] and were compared between groups by the Mann–Whitney U test. Count data are expressed as n or % and were compared between groups by the chi-squared test (χ²) or Fisher's exact test. The Kaplan–Meier method was used to draw the survival curves of the two groups of patients, and the log-rank χ2 test was used to compare the survival rate between the two groups. P < 0.05 indicated a significant difference. The forward selection method and backward elimination method for logistic regression were combined. Variables with clinical significance and P<0.05 were selected as variables in the prediction model from the baseline data, and an obstructive CAD risk prediction model was established. After the model was established, the Stata command "nomogram" was used to establish the obstructive CAD risk prediction score, the score was assigned according to the risk ratio of the variable from the regression analysis, and the nomogram was drawn. The area under the receiver operating characteristic (ROC) curve (AUC) was used to evaluate the predictive ability of the screened clinical indicators for obstructive CAD. 3. Results 3 .1 Study population A total of 1200 patients with suspected CCS who met the inclusion criteria were enrolled during the study period. The participants were randomly divided into groups of 600 at a 1:1 ratio. Eight patients in the CCTA group and 6 patients in the ICA group were lost to follow-up. 3 .2 Characteristics of patients There were no statistically significant differences in sex, age, cardiovascular risk factors, severity of cardiovascular lesions, or medication between the two groups (P≥0.05) (Table 1). A total of 1186 patients were analysed; 56.8% of the patients had coronary artery stenosis ≥50%, and the percentage of patients with obstructive CAD was 45.2%. Among the three types of chest pain, atypical angina pectoris was the most common, accounting for 40.1%, followed by typical angina pectoris, accounting for 35.0%, and nonangina chest pain with ECG changes was the least common, accounting for 25.0%. Table 1 Clinical data of the included patients CCTA group (n＝592) ICA group (n＝594) Z or χ 2 P Demographic Data Male (%) 324 (54.73%) 296 (49.83%) 1.426 0.232 Age (y) 61 (55, 67) 63 (57, 67) -1.342 0.180 Cardiovascular Risk Factors Hypertension (%) 340 (57.43%) 378 (63.64%) 2.389 0.122 Diabetes (%) 114 (19.26%) 154 (25.93%) 3.770 0.052 Hyperlipemia (%) 178 (30.07%) 212 (35.70%) 2.124 0.145 Smoking history (%) 268 (45.27%) 246 (41.41%) 0.969 0.325 CHD family history (%) 74 (12.50%) 82 (13.80%) 0.206 0.650 Laboratory Index Ccr (μmol/L) 71 (62, 81) 71 (59, 81) -0.505 0.613 UA (μmol/L) 302 (251, 365) 296 (254, 352) -0.415 0.678 CK-MB (U/L) 13 (11, 15) 13 (11, 15) -0.285 0.776 PT (s) 12.90 (12.50, 13.30) 12.80 (12.50, 13.20) -1.643 0.100 INR 0.97 (0.94, 1.01) 0.96 (0.93, 1.01) -1.426 0.154 Fib (g/L) 3.12 (2.74, 3.57) 3.13 (2.76, 3.60) -0.479 0.632 D-dimer(µg/ml) 0.26 (0.21, 0.37) 0.26 (0.21, 0.37) -0.267 0.789 HCY (μmol/L) 12.50 (10.20, 14.90) 11.80 (9.50, 15.40) -1.323 0.186 H-CRP (mg/L) 1.07 (0.51, 2.40) 1.20 (0.55, 3.07) -1.614 0.107 Lipoprotein-a (nmol/L) 25.45 (13.45, 58.83) 24.10 (9.25, 57.40) -1.698 0.090 TC (mmol/L) 4.31 (3.59, 5.12) 4.35 (3.72, 5.00) -0.517 0.605 TG (mmol/L) 1.46 (1.06, 2.04) 1.53 (1.10, 2.25) -0.832 0.406 LpA (g/L) 1.28 (1.11, 1.40) 1.26 (1.14, 1.45) -0.694 0.487 LpB (g/L) 0.98 (0.78, 1.17) 0.97 (0.83, 1.17) -0.276 0.783 HDL-c (mmol/L) 1.06 (0.90, 1.24) 1.03 (0.87, 1.22) -0.638 0.524 LDL-c (mmol/L) 2.78 (2.15, 3.50) 2.83 (2.20, 3.43) -0.020 0.984 FFA (mmol/L) 0.36 (0.25, 0.50) 0.39 (0.26, 0.52) -1028 0.304 LAAP (mm) 35 (33, 38) 36 (33, 39) -1.547 0.122 LVEDD (mm) 50 (48, 52) 49 (47, 52) -1.098 0.272 LVEF (%) 62 (61, 65) 62 (60, 65) -0.158 0.875 Classification of chest pain 0.419 0.811 Typical angina pectoris (%) 210 (35.47%) 204 (34.34%) Atypical angina pectoris (%) 230 (38.85%) 246 (41.41%) Nonangina chest pain with electrocardiogram changes (%) 152 (25.68%) 144 (24.24%) Degree of coronary artery disease Obstructive CAD (%) 270 (45.61%) 266 (44.78%) 0.041 0.840 Single vessel disease (%) 128 (21.62%) 114 (19.19%) 0.539 0.463 Double vessel disease (%) 72 (12.16%) 84 (14.14%) 0.508 0.476 Triple vessel disease (%) 70 (11.82%) 70 (11.78%) ＜0.001 0.988 Left Main Disease (%) 22 (3.72%) 18 (3.03%) 0.214 0.644 Adverse reaction Allergy to contrast media (%) 28 (4.73%) 16 (2.69%) 1.720 0.190 Drug use Aspirin (%) 398 (67.23%) 410 (69.02%) 0.220 0.639 Clopidogrel (%) 224 (37.84%) 192 (32.32%) 1.980 0.159 Statins (%) 464 (78.38%) 452 (76.09%) 0.440 0.507 β-blocker (%) 336 (56.76%) 342 (57.58%) 0.041 0.840 ACEI/ARB (%) 198 (30.07%) 200 (33.67%) 0.886 0.347 Ticagrelor (%) 48 (8.11%) 74 (12.46%) 1.986 0.159 CCB (%) 186 (31.42%) 184 (30.98%) 0.014 0.907 Data are presented as n (%) or M (P25, P75). 3 .3 Primary clinical endpoints In the CCTA group, ICA was performed in 292 of 592 patients to confirm the diagnosis of obstructive CAD, resulting in a 50.7% reduction in the use of ICA compared with the 100% rate (594/594) in the ICA group (P < 0.001) (Figure 2). In the CCTA group, 270 out of 292 patients who underwent ICA were ultimately diagnosed with obstructive CAD, and the percentage of patients with a nonessential ICA was 7.5%. In the ICA group, 266 of 594 patients underwent ICA, and the percentage of patients who underwent surgery via the nonessential ICA was 55.2% (P < 0.001) (Figure 3). In the CCTA group, 56 of 292 patients who underwent ICA did not undergo revascularization (including PCI and CABG), while in the ICA group 380 of 594 patients who underwent ICA did not undergo revascularization (19.2% vs. 64.0%, P < 0.001) (Figure 4). 3 .4 Secondary clinical endpoints There was no significant difference in the MACE rate between the two groups. In the CCTA group, 18 patients were readmitted due to severe angina pectoris, among whom 8 patients underwent CCTA only during the first hospitalization; no obvious vascular stenosis was found at ICA upon readmission, and optimized drug therapy was administered. Six patients underwent ICA and stent implantation during the first hospitalization, no in-stent stenosis or significant stenosis of other vessels was found after ICA was readmitted, and optimized drug therapy was given. Two patients who did not undergo stenting after ICA during the first hospitalization were readmitted with stenting. Two patients underwent stent implantation during the first hospitalization, and ICA showed no stenosis in the stent upon readmission, while other vascular lesions progressed, and stent implantation was performed. In the ICA group, 8 patients were readmitted due to severe angina pectoris, 2 of whom underwent stent implantation during the first hospitalization, and ICA showed no stenosis in the stent upon readmission, while other vascular lesions progressed, and stent implantation was performed. Six patients underwent ICA and stent implantation during the first hospitalization, no in-stent stenosis or significant stenosis of other vessels was found after ICA was readmitted, and optimized drug therapy was started. There was no cardiac death, myocardial infarction, or stroke in the two groups during the 1-year follow-up, as shown in Table 2. Kaplan‒Meier curves were drawn to compare the MACE-free survival rate between the two groups during follow-up, which was 97.0% in the CCTA group and 98.7% in the ICA group. The log-rank test showed no significant difference (log-rank c²=1.996, P=0.158), as shown in Figure 5. Contrast allergy occurred in 28 patients in the CCTA group and 16 patients in the ICA group (P > 0.190) (Table 1). The median hospitalization costs were 9194.61 yuan in the CCTA group and 10215.67 yuan in ICA group (P < 0.001) (Figure 6). Table 2 MACE during follow-up CCTA group (n＝592) ICA group (n＝594) MACE (%) 18 (3.04%) 8 (1.35%) Cardiac death (%) 0 (0) 0 (0) Myocardial infarction (%) 0 (0) 0 (0) Stroke (%) 0 (0) 0 (0) Readmission for severe angina (%) 18 (3.04%) 8 (1.35%) Unplanned revascularization (%) 4 (0.68%) 2 (0.34%) The data in the table are presented as examples (%) 3 .5 Logistic regression analysis The forward selection method and the backward elimination method were combined for logistic regression. The baseline data of the patients included sex, age, history of hypertension, diabetes status, hyperlipidaemia status, smoking status, family history of CHD, creatinine, uric acid, creatine kinase–myocardial band (CK-MB), prothrombin time, international normalized ratio (INR), fibrinogen quantification, D-dimer, homocysteine, hypersensitive CRP, free fatty acid, left atrial anterior and posterior diameter, left ventricular diastolic end diameter and left ventricular ejection fraction (LVEF); the variables with P<0.05 for predicting obstructive CAD were creatinine (OR = 1.027; 95% CI: 1.015-1.040; P< 0.001), age (OR＝1.030; 95% CI: 1.010-1.050; P＝0.003), physical activity or emotional agitation-induced symptoms (OR = 2.362; 95% CI: 1.010-1.050; P = 0.003), hyperlipidaemia (OR = 1.424; 95% CI: 1.128-1.714; P = 0.015), diabetes (OR = 1.793; 95% CI: 1.181-2.724; P = 0.006), and smoking history (OR = 1.785; 95% CI: 1.237-2.575; P = 0.002), as shown in table 3. Table 3 Variables screened by logistic regression to predict obstructive CAD OR value 95% CI P value Ccr 1.027 1.015—1.040 <0.001 Age 1.030 1.010—1.050 0.003 Induced by physical activity or emotional excitement 2.362 1.663—3.356 <0.001 Hyperlipemia 1.424 1.128—1.714 0.015 Diabetes 1.793 1.181—2.724 0.006 Smoking history 1.785 1.237—2.575 0.002 3 .6 Establishment and validation of the obstructive CAD prediction model From the baseline data of patients in this study, variables that had clinical significance and statistical significance (P<0.05) were input as variables in the prediction model to establish a risk prediction model for obstructive CAD. According to the risk ratio of the variable in the regression analysis, the risk prediction score of obstructive CAD was established, and a line chart was drawn (Figure 7). The ROC curve was used to evaluate the predictive ability of the selected clinical indicators for obstructive CAD, and the AUC was 0.721, indicating that the model had a strong ability to distinguish patients at high or low risk of obstructive CAD in the selected population of this study (Figure 8). 4. Discussion In this study assessing the risks and benefits of noninvasive CCTA versus invasive ICA, patients with typical angina, atypical angina, and nonangina chest pain with electrocardiographic changes who were suspected to have CCS were randomly assigned to the CCTA group or ICA group. In the enrolled population, CCTA was shown to act as a "safety gatekeeper" for ICA, and using CCTA as a first-line test reduced nonessential ICA without increasing MACE. This study also confirmed that CCTA can reduce the cost of diagnostic evaluation in patients with stable chest pain. At the same time, the outpatient characteristics of CCTA can further shorten the diagnosis and treatment time of patients and reduce the waste of unnecessary medical resources. Patients are more willing to undergo the noninvasive CCTA. 4.1 Comparison with other relevant studies The PROMISE study [ 16 ] and SCOT-HEART study [ 17 ] showed that CCTA, as a first-line examination for stable patients with suspected CHD, could detect a higher rate of obstructive CAD than other noninvasive diagnostic tests, including exercise ECG, nuclear stress tests and stress echocardiography, making the use of ICA more reasonable. The retrospective PLATFORM study [ 18 ] revealed that computed tomography-derived fractional flow reserve (CT-FFR) reduced the use of ICA by 61% and significantly reduced the proportion of patients with nonobstructive CAD on ICA. However, the present study did not assess the value of CCTA alone. A randomized single-centre study by Dewey et al. [ 19 ] reported that CCTA as a first-line test could significantly increase the rate of obstructive CAD caused by ICA, but the included population had atypical angina pectoris, with a prevalence of obstructive CAD of only 13%. In contrast, our study included patients with typical angina pectoris and nonangina chest pain with ECG changes, and the prevalence of obstructive CAD was 45.2%, expanding the scope of application of CCTA as a "safety gatekeeper" for ICA to some extent. The early study by Dewey et al. [ 19 ] randomized 340 patients, 168 of whom were assigned to CCTA and 172 to ICA. The primary clinical endpoint of the study was complications within 48 hours after CCTA or ICA, of which serious complications (including myocardial infarction, death, stroke, etc.) were uncommon (0.3%) and had similar rates in the two groups. However, complications such as haematoma at the puncture site and secondary bleeding at the puncture site were significantly less common in the CCTA group than in the ICA group. Our study compared the number of patients with contrast agent allergy in the CCTA group and the ICA group and found that there were more patients with contrast agent allergy in the CCTA group, but this difference was not significant. The reason may be that some patients in the CCTA group received two contrast agent injections in a short period of time, which may increase the likelihood of contrast agent allergy. In addition, Dewey et al [ 19 ] completed a 3.3-year (median) follow-up of 329 patients in the CCTA and ICA groups and found few MACE events: 7 of 167 patients in the CCTA group and 6 of 162 patients in the ICA group. This demonstrated that CCTA guidance alone was safe and did not increase long-term clinical events in patients who did not have ICA in the CCTA group, which was also confirmed in our study, but the follow-up time in our study was shorter, at 1 year. The CONSERVE study [ 20 ] also demonstrated that first-line use of CCTA can reduce unnecessary ICA examination, but in the CONSERVE study, 33.2% of the patients had ≥ 50% stenosis in either coronary artery, compared with 56.8% in our study. This suggests that our study evaluated the efficacy of CCTA in a population with a relatively higher risk of CHD. The CAT-CAD randomized single-centre study [ 21 ] , based on the 2013 European Society of Cardiology (ESC) guidelines for the management of stable CAD, included patients with an ICA indication, including patients with typical angina with a left ventricular ejection fraction 85%. PTP was assessed based on criteria for age, sex, and angina symptoms. The CAT-CAD study [ 21 ] showed that the use of CCTA as a first-line test reduced the number of patients with ICA by 64.4% and the number of non-revascularization patients after ICA by 88.1% compared to those who underwent ICA. However, that study included only 120 patients in total and 45 patients with typical angina. The DISCHARGE trial [ 22 ] was a randomized controlled study comparing CCTA and ICA as initial tests in 3561 patients with stable chest pain and a moderate predictive probability of CHD. At 3.5 years of follow-up, there was no substantial difference between the CCTA and ICA groups in the incidence of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke, and the incidence of MACE was very low, at 2.1% for CCTA and 3.0% for ICA. There was also no difference in the incidence of angina during follow-up. These results are similar to our conclusion. However, the proportion of patients enrolled in the DISCHARGE trial who had at least 50% stenosis in any coronary artery was 25.7%, compared with 56.8% in our study, and the patients enrolled in our study were at higher risk for obstructive CAD. 4.2 Limitations and prospects This study was conducted at a single centre, and patients were not enrolled on consecutive working days, which could introduce some bias. Second, this study chose nonessential ICA rather than MACE as the primary endpoint because the MACE rate was very low in the study population. A much larger sample will be needed for future studies. In addition, the MACE follow-up in this study only ran for 1 year, so longer follow-up will be needed to test the results of this study. Third, due to the small sample size, this study was unable to provide a robust assessment of the clinical complications associated with the two examinations. Fourth, patients with impaired renal function were excluded. One study showed that intravenous iodine contrast agents are less risky than arterial iodine injections [ 23 ] , which supports the better safety profile of CCTA. Fifth, the sample was relatively small for establishing a predictive model for obstructive CAD. Future studies can develop a risk score model for obstructive CAD with stronger predictive power based on a larger sample size. 5. Conclusion In patients with suspected CCS, including typical angina, atypical angina and nonangina chest pain with abnormal electrocardiogram results, the use of CCTA as a first-line diagnostic test can reduce the unnecessary incidence of ICA and hospitalization costs without increasing the incidence of MACE. A risk prediction model of obstructive CAD was established based on the baseline data of the patients enrolled in this study, providing a clinical basis for the decision to use CCTA or ICA. Patients with a low probability of obstructive CAD can be given priority for CCTA, while patients with a high probability can be given priority for ICA. Declarations Ethics approval and consent to participate The study was approved by the local ethics committee of TEDA International Cardiovascular Hospital. All experiments were performed in accordance with relevant guidelines and regulations such as the Declaration of Helsinki and the patients signed the informed consent form and agreed to be published. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed in the present study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding Funded by Tianjin Key Medical Discipline (Specialty) Construction Project (TJYXZDXK-020A). Authors' contributions Clinical data collection and analysis were performed by HL and RJF. CTCA imaging data was collected and analyzed by WZ. The first draft of the manuscript was written by LXD, and all authors commented on previous versions of the manuscript. LXD and RJF also did the statistics work. RJ contributed to the study conception and design. All authors read and approved the final manuscript. Corresponding author: Correspondence to Rui Jing. Acknowledgements American Journal Experts part of Springer Nature did some work for the English polishing. References Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes [J]. Eur Heart J. 2020;41(3):407–77. Collet JP, Thiele H, Barbato E, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation [J]. Eur Heart J. 2021;42(14):1289–367. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC) [J]. Eur Heart J. 2018;39(2):119–77. Narula J, Chandrashekhar Y, Ahmadi A, et al. SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography: A Report of the Society of Cardiovascular Computed Tomography [J]. J Cardiovasc Comput Tomogr. 2021;15(3):192–217. Task Force M, Montalescot G, Sechtem U, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology [J]. Eur Heart J. 2013;34(38):2949–3003. Patel MR, Peterson ED, Dai D, et al. Low diagnostic yield of elective coronary angiography [J]. N Engl J Med. 2010;362(10):886–95. Moschovitis A, Cook S, Meier B. Percutaneous coronary interventions in Europe in 2006 [J]. EuroIntervention. 2010;6(2):189–94. Levenson B, Albrecht A, Gohring S, et al. [6th report of the German Association of Cardiologists in private practice (BNK) on quality assurance in cardiac catheterization and coronary intervention 2006–2009] [J]. Herz. 2011;36(1):41–9. Schuetz GM, Schlattmann P, Dewey M. Use of 3x2 tables with an intention to diagnose approach to assess clinical performance of diagnostic tests: meta-analytical evaluation of coronary CT angiography studies [J]. BMJ. 2012;345:e6717. Budoff MJ, Kalia N, Cole J, et al. Diagnostic accuracy of Visipaque enhanced coronary computed tomographic angiography: a prospective multicenter trial [J]. Coron Artery Dis. 2017;28(1):52–6. Budoff MJ, Li D, Kazerooni EA, et al. Diagnostic Accuracy of Noninvasive 64-row Computed Tomographic Coronary Angiography (CCTA) Compared with Myocardial Perfusion Imaging (MPI): The PICTURE Study, A Prospective Multicenter Trial [J]. Acad Radiol. 2017;24(1):22–9. Neglia D, Rovai D, Caselli C et al. Detection of significant coronary artery disease by noninvasive anatomical and functional imaging [J]. Circ Cardiovasc Imaging, 2015, 8(3). Mancini GBJ, Leipsic J, Budoff MJ, et al. CT Angiography Followed by Invasive Angiography in Patients With Moderate or Severe Ischemia-Insights From the ISCHEMIA Trial [J]. JACC Cardiovasc Imaging. 2021;14(7):1384–93. Tonino PA, Fearon WF, De Bruyne B, et al. Angiographic versus functional severity of coronary artery stenoses in the FAME study fractional flow reserve versus angiography in multivessel evaluation [J]. J Am Coll Cardiol. 2010;55(25):2816–21. Marwick TH, Cho I. Finding the Gatekeeper to the Cardiac Catheterization Laboratory: Coronary CT Angiography or Stress Testing? [J]. J Am Coll Cardiol. 2015;65(25):2747–56. Douglas PS, Hoffmann U, Patel MR, et al. Outcomes of anatomical versus functional testing for coronary artery disease [J]. N Engl J Med. 2015;372(14):1291–300. investigators S-H. CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicentre trial [J]. Lancet, 2015, 385(9985): 2383–91. Douglas PS, Pontone G, Hlatky MA, et al. Clinical outcomes of fractional flow reserve by computed tomographic angiography-guided diagnostic strategies vs. usual care in patients with suspected coronary artery disease: the prospective longitudinal trial of FFR(CT): outcome and resource impacts study [J]. Eur Heart J. 2015;36(47):3359–67. Dewey M, Rief M, Martus P, et al. Evaluation of computed tomography in patients with atypical angina or chest pain clinically referred for invasive coronary angiography: randomised controlled trial [J]. BMJ. 2016;355:i5441. Chang HJ, Lin FY, Gebow D, et al. Selective Referral Using CCTA Versus Direct Referral for Individuals Referred to Invasive Coronary Angiography for Suspected CAD: A Randomized, Controlled, Open-Label Trial [J]. JACC Cardiovasc Imaging. 2019;12(7 Pt 2):1303–12. Rudzinski PN, Kruk M, Kepka C, et al. The value of Coronary Artery computed Tomography as the first-line anatomical test for stable patients with indications for invasive angiography due to suspected Coronary Artery Disease: CAT-CAD randomized trial [J]. J Cardiovasc Comput Tomogr. 2018;12(6):472–9. Group DT, Maurovich-Horvat P, Bosserdt M et al. CT or Invasive Coronary Angiography in Stable Chest Pain [J]. N Engl J Med, 2022. Wichmann JL, Katzberg RW, Litwin SE, et al. Contrast-Induced Nephrop [J] Circulation. 2015;132(20):1931–6. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 25 Feb, 2025 Read the published version in BMC Cardiovascular Disorders → Version 1 posted Editorial decision: Revision requested 27 Jan, 2025 Reviews received at journal 26 Jan, 2025 Reviews received at journal 22 Jan, 2025 Reviewers agreed at journal 22 Jan, 2025 Reviewers agreed at journal 21 Jan, 2025 Reviews received at journal 21 Jan, 2025 Reviewers agreed at journal 21 Jan, 2025 Reviewers agreed at journal 21 Jan, 2025 Reviewers agreed at journal 21 Jan, 2025 Reviews received at journal 18 Jan, 2025 Reviewers agreed at journal 08 Jan, 2025 Reviewers invited by journal 16 Aug, 2024 Editor invited by journal 26 Jun, 2024 Editor assigned by journal 24 Jun, 2024 Submission checks completed at journal 24 Jun, 2024 First submitted to journal 18 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4597914","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":321111634,"identity":"9b9b586f-3e32-4693-adb3-43e05b19c25e","order_by":0,"name":"Huan Luo","email":"","orcid":"","institution":"TEDA International Cardiovascular Hospital, Tianjin University","correspondingAuthor":false,"prefix":"","firstName":"Huan","middleName":"","lastName":"Luo","suffix":""},{"id":321111642,"identity":"fc154e7d-e85a-41be-a8d3-3335b3895d51","order_by":1,"name":"Wei Zhu","email":"","orcid":"","institution":"Tianjin Second People’s 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Jing","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAx0lEQVRIiWNgGAWjYDACHoYEhoSK/3L8zMyHHxCv5cEZZmPJdrY0A2K1MDA+bGNO3HCeR0GCKB3mPAeefUhsY0vcfJiHwYChxiaaoBbL3obkGQnneIy3HeY98IDhWFpuAyEtBucZkhkSyiRktx3mSzBgbDhMrBY2A8bNzTwGEsRpOdsA1NKWoLiBmWgtZw4AtZw5YCxxGBjICUT55UxOMuOPigNy/P2HDz/4UGNDWAswYhIQ7ARcilAB+wHi1I2CUTAKRsHIBQAj4UF0FRqqHQAAAABJRU5ErkJggg==","orcid":"","institution":"TEDA International Cardiovascular Hospital, Tianjin University","correspondingAuthor":true,"prefix":"","firstName":"Rui","middleName":"","lastName":"Jing","suffix":""}],"badges":[],"createdAt":"2024-06-18 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2","display":"","copyAsset":false,"role":"figure","size":77895,"visible":true,"origin":"","legend":"\u003cp\u003eProportion of patients who underwent ICA surgery in the two groups\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4597914/v1/c9bb2ee44f4031315a6c1d10.jpeg"},{"id":60621087,"identity":"b6baa8c8-3036-4857-a07d-518e4a0006fc","added_by":"auto","created_at":"2024-07-18 20:59:00","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":93663,"visible":true,"origin":"","legend":"\u003cp\u003eProportion of patients diagnosed with nonobstructive CAD after ICA in both groups\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4597914/v1/36f0edf80800c443f23ba71b.jpeg"},{"id":60621093,"identity":"57502138-d612-4c89-a69e-f1b895fbebe6","added_by":"auto","created_at":"2024-07-18 20:59:00","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":94361,"visible":true,"origin":"","legend":"\u003cp\u003eProportion of patients without revascularization after ICA in the two groups\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4597914/v1/a9e3872fd3e57b6f184f135a.jpeg"},{"id":60621091,"identity":"10919e81-dee4-44ac-8a57-cfec353084dc","added_by":"auto","created_at":"2024-07-18 20:59:00","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":93247,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan‒Meier curves of the two groups\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4597914/v1/8a6f11ec59a626e7ad684907.jpeg"},{"id":60621884,"identity":"c8dec5c0-062d-4631-a2ca-a1254d062f3b","added_by":"auto","created_at":"2024-07-18 21:07:00","extension":"jpeg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":229040,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of hospitalization costs between the two groups\u003c/p\u003e\n\u003cp\u003eA: Overall distribution B: Local amplification\u003c/p\u003e","description":"","filename":"floatimage6.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4597914/v1/17d78e11472903a9e757737a.jpeg"},{"id":60621090,"identity":"51ac36f2-14b3-4c6b-885e-9c3a7b86f021","added_by":"auto","created_at":"2024-07-18 20:59:00","extension":"jpeg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":245597,"visible":true,"origin":"","legend":"\u003cp\u003eRisk prediction score for obstructive CAD\u003c/p\u003e","description":"","filename":"floatimage7.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4597914/v1/071751ed8f711293301e27fe.jpeg"},{"id":60621094,"identity":"85a4c985-d623-490c-a5c8-b046e0fb586c","added_by":"auto","created_at":"2024-07-18 20:59:00","extension":"jpeg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":198546,"visible":true,"origin":"","legend":"\u003cp\u003eROC curve\u003c/p\u003e","description":"","filename":"floatimage8.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4597914/v1/2109584f89ae24e146b53f3b.jpeg"},{"id":77622703,"identity":"146163c5-bfef-404d-9513-b216808f6e04","added_by":"auto","created_at":"2025-03-03 16:09:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2514979,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4597914/v1/0b017158-f29c-4d9a-aed1-3656ac499703.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of the clinical value of CCTA as the preferred screening method in patients with chronic coronary syndrome","fulltext":[{"header":"1. Background","content":"\u003cp\u003eCoronary heart disease (CHD) is a dynamic pathological process characterized by the accumulation of epicardial atherosclerotic plaques and changes in circulatory function. It is divided into two categories: acute coronary syndrome (ACS) and chronic coronary syndrome (CCS)\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. In clinical practice, the diagnostic and treatment processes of ACS are relatively fixed. According to the symptoms of chest pain, electrocardiogram (ECG) changes and elevated myocardial injury markers, the risk for ACS can be rapidly stratified, and the corresponding diagnosis and treatment process can be formulated\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. The diagnosis of CCS is more difficult because patients with CCS have more atypical symptoms, a longer course of disease, and more different diseases need to be differentiated. The 2019 European Society of Cardiology (ESC) guidelines for the diagnosis and management of CCS recommend coronary computed tomographic angiography (CCTA) as a first-line test for patients with a low or intermediate clinical likelihood of CHD \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. The Cardiovascular CT Society 2021 expert consensus recommends CCTA as the first-line test to evaluate patients with or without prior CHD presenting with stable ischaemic symptoms \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. However, in the current clinical setting, ICA is still used as the preferred examination for the early diagnosis of CCS patients because ICA is the gold standard for the diagnosis of CHD\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. The advantage of ICA over CCTA is that percutaneous coronary intervention (PCI) can be performed at the same time as lesion detection. However, evidence from the United States \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e and Europe \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e suggests that ICA is overused; in more than half of the patients who underwent ICA, the coronary vessels showed normal or no more than 50% stenosis. At the same time, ICA can lead to rare but potentially life-threatening complications\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Therefore, ICA is an invasive, expensive, and possibly unnecessary procedure for these patients.\u003c/p\u003e \u003cp\u003eCCTA is the most accurate non-invasive test for diagnosing CHD\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Prospective, multicentre studies have demonstrated the diagnostic accuracy of CCTA in patients with suspected but undiagnosed CHD, with sensitivities ranging from 85\u0026ndash;99% and specificities ranging from 64\u0026ndash;92%\u003csup\u003e[\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. The ISCHEMIA study \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e showed a high degree of agreement between CCTA and ICA in identifying patients with significant coronary stenosis without left main disease. The ICA confirmed that only 4.9% of the 1,593 patients without left main disease with at least a single-vessel disease identified by CCTA had no significant coronary stenosis. Given that the actual prevalence of CHD is lower than expected and that not all patients with \u0026ge;\u0026thinsp;50% coronary artery stenosis require invasive treatment, two-thirds of those with 50%-70% coronary artery stenosis have no significant functional significance\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. Therefore, CCTA is touted as a \"safety gatekeeper\" for ICA, with the aim of selecting patients for ICA more accurately \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. However, in patients with suspected CCS, there is still a lack of studies on the downstream efficacy, safety and cost of using CCTA as the first-line examination to decide whether the patient should undergo ICA. There have been few comparative studies in China. The aim of this study was to investigate whether CCTA can effectively reduce the use of ICA and reduce the cost of diagnosis and treatment in patients with suspected CCS without increasing the incidence of major adverse cardiovascular events (MACE).\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e.1\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eResearch subjects\u0026nbsp;\u003c/strong\u003eFrom January 2021 to December 2022, patients with suspected CCS were enrolled in three categories: typical angina pectoris, atypical angina pectoris, and nonangina chest pain with electrocardiogram changes.\u0026nbsp;There are three characteristics of typical AP: 1) contractive discomfort in the anterior chest, neck, shoulder, jaw, or arm; 2) physical activity or emotional excitement; and 3)\u0026nbsp;symptoms that resolve after about 5 minutes of rest or the use of nitrates. Patients with atypical angina pectoris were defined as having two of these three features, and patients with nonangina chest pain were defined as having one or none\u003csup\u003e[1]\u003c/sup\u003e.\u0026nbsp;Electrocardiographic changes indicate the presence of any one of the following: Q waves, left bundle-branch block, ST-segment abnormality, or T-wave abnormality.\u0026nbsp;The following patients were excluded: A, previous history of CHD; B, ACS, including ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, and unstable angina pectoris; C, typical angina patients with left ventricular ejection fraction \u0026lt; 50%; D, nonsinus rhythm (atrial fibrillation and frequent premature beats, etc.); E, unable to hold breath for 5 seconds; F. refusal or inability to provide informed consent; G, aged less than 30 years; H, renal insufficiency; I, known congenital heart disease.\u0026nbsp;This study met the ethical standards established by our hospital. Informed consent was obtained from all participants or their family members before CCTA or ICA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e.2\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eMethods\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e.2.1\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eGrouping\u0026nbsp;\u003c/strong\u003eThe enrolled patients were randomly divided into two groups at a ratio of 1:1 by a random number table:\u0026nbsp;(1) CCTA+ICA strategy (CCTA group): CCTA was performed first; if CCTA results showed positive obstructive coronary\u0026nbsp;artery\u0026nbsp;disease (CAD), typical angina with coronary artery stenosis ranging from 50% to 70% or vascular segments could not be analysed due to severe calcification, ICA was further performed for definitive diagnosis. (2) In the ICA group (direct ICA strategy), ICA examination was performed directly.\u0026nbsp;In both tests, obstructive CAD was defined as at least one 50% diameter stenosis in the left main coronary artery or at least one 70% diameter stenosis in other coronary arteries.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e.2.2\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCCTA\u0026nbsp;\u003c/strong\u003ePatients were scanned with a Siemens dual-source CT (Somatom Definition flash).\u0026nbsp;First, continuous scanning from the root of the autonomic artery to the apex of the heart was performed with a collimation of 24 mm\u0026times;1.2 mm, a pitch of 1.2 mm, and a slice thickness of 1.5 mm in one respiratory motion at a tube voltage of 120 kV.\u0026nbsp;Then, a high-pressure syringe was used to inject iodine contrast agent and normal saline into the anterior elbow vein at a flow rate of approximately 5 ml/s. The test bolus technique was applied to calculate the delayed trigger scan time, and the area of interest was selected at the aortic root level to monitor CT values. The peak time plus 5 s was taken as the delayed trigger scan time.\u0026nbsp;CCTA analysis was performed independently by readers who were unaware of the results of the clinical data, and discordant results were resolved by at least two readers.\u0026nbsp;The degree of coronary stenosis was analysed by curved planar reconstruction (CPR) and maximum-intensity projection (MIP) of a Siemens image postprocessing workstation. All segments larger than 2 mm in diameter were classified into the following groups: no stenosis, 1% to 49% stenosis, 50% to 70% stenosis, and more than 70% stenosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e.2.3\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eICA\u0026nbsp;\u003c/strong\u003eICA was performed on patients using standard techniques on a Philips FD20 single-channel X-ray tube fluoroscopy device.\u0026nbsp;We used the standard Judkins method. The coronary arteries were examined in multiple positions; at least 2 positions were selected for each lesion, and 0.2 mg of nitroglycerine was applied to the target vessel if necessary.\u0026nbsp;The luminal diameter stenosis rate, estimated by visual inspection, was equal to 1 \u0026minus; the minimum lumen diameter/mean diameter of the reference segment, multiplied by 100%.\u0026nbsp;The\u0026nbsp;results were determined by consensus among three senior cardiologists qualified for interventional treatment of CHD.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e.2.4\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eIndicators of observation\u0026nbsp;\u003c/strong\u003eBaseline data (including sex, age, hypertension status, diabetes status, hyperlipidaemia status, smoking history, family history of CHD, chest pain classification, electrocardiogram results, etc.), degree of CAD, contrast agent allergy status, medication use and hospitalization costs were compared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e.2.5\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePrimary and secondary clinical endpoints\u0026nbsp;\u003c/strong\u003eThe primary clinical endpoint of the study was nonessential ICA, which was defined as ICA done in patients who were diagnosed as negative for obstructive CAD.\u0026nbsp;The secondary endpoints were (1) MACE, including cardiac death (any death that could not be explained by noncardiac causes), nonfatal myocardial infarction, stroke, readmission for severe angina symptoms, and unplanned revascularization (PCI or CABG was performed according to the patient\u0026apos;s condition during the follow-up period); (2) hospitalization expenses; and (3) contrast-induced allergic conditions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e.2.6\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTherapeutic management\u0026nbsp;\u003c/strong\u003eRevascularization was planned for patients with \u0026ge;50% diameter stenosis in the left main coronary artery or \u0026ge;70% diameter stenosis in other epicardial artery segments. Small collateral lesions with a diameter less than 2 mm that were controlled by drugs were treated conservatively with drugs.\u0026nbsp;Regardless of the number of vessels processed at ICA, the number of stents implanted, and the need for a second completion of residual vascular disease treatment, a single PCI was performed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e.2.7\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFollow-up\u0026nbsp;\u003c/strong\u003ePatients were followed up by telephone or in the outpatient clinic after discharge. The follow-up time points were 1 month (\u0026plusmn;1 week), 3 months (\u0026plusmn;1 week), 6 months (\u0026plusmn;1 week) and 12 months (\u0026plusmn;1 week). MACE that occurred during follow-up were recorded. The study procedure is shown in Figure 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e.3\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eStatistical analysis\u0026nbsp;\u003c/strong\u003eSPSS 25.0 was used to process and analyse the research data. Normally distributed measurement data are expressed as mean \u0026plusmn; standard deviation (x ̅\u0026plusmn;s). Comparisons between groups were performed by the two-independent-sample t test. The measurement data that did not meet the normal distribution are expressed as median (interquartile range) [M (P25, P75)] and were compared between groups by the Mann\u0026ndash;Whitney U test. Count data are expressed as n or % and were compared between groups by the chi-squared test (\u0026chi;\u0026sup2;) or Fisher\u0026apos;s exact test. The Kaplan\u0026ndash;Meier method was used to draw the survival curves of the two groups of patients, and the log-rank \u0026chi;2 test was used to compare the survival rate between the two groups. P \u0026lt; 0.05 indicated a significant difference. The forward selection method and backward elimination method for logistic regression were combined. Variables with clinical significance and P\u0026lt;0.05 were selected as variables in the prediction model from the baseline data, and an obstructive CAD risk prediction model was established. After the model was established, the Stata command \u0026quot;nomogram\u0026quot; was used to establish the obstructive CAD risk prediction score, the score was assigned according to the risk ratio of the variable from the regression analysis, and the nomogram was drawn. The area under the receiver operating characteristic (ROC) curve (AUC) was used to evaluate the predictive ability of the screened clinical indicators for obstructive CAD.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003cstrong\u003e.1\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eStudy population\u0026nbsp;\u003c/strong\u003eA total of 1200 patients with suspected CCS who met the inclusion criteria were enrolled during the study period. The participants were randomly divided into groups of 600 at a 1:1 ratio.\u0026nbsp;Eight patients in the CCTA group and 6 patients in the ICA group were lost to follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003cstrong\u003e.2\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCharacteristics of patients\u0026nbsp;\u003c/strong\u003eThere were no statistically significant differences in sex, age, cardiovascular risk factors, severity of cardiovascular lesions, or medication between the two groups (P\u0026ge;0.05) (Table 1).\u0026nbsp;A total of 1186 patients were analysed; 56.8% of the patients had coronary artery stenosis \u0026ge;50%, and the percentage of patients with obstructive CAD was 45.2%.\u0026nbsp;Among the three types of chest pain, atypical angina pectoris was the most common, accounting for 40.1%, followed by typical angina pectoris, accounting for 35.0%, and nonangina chest pain with ECG changes was the least common, accounting for 25.0%.\u003c/p\u003e\n\u003cp\u003eTable 1\u0026nbsp;Clinical data of the included patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"565\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003eCCTA group\u0026nbsp;(n＝592)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.67844522968198%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eICA group\u0026nbsp;(n＝594)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.070671378091873%\" valign=\"top\"\u003e\n \u003cp\u003eZ or \u0026chi;\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDemographic Data\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eMale\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e324\u0026nbsp;(54.73%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e296\u0026nbsp;(49.83%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1.426\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.232\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eAge\u0026nbsp;(y)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e61\u0026nbsp;(55,\u0026nbsp;67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e63\u0026nbsp;(57,\u0026nbsp;67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-1.342\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.180\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCardiovascular Risk Factors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eHypertension\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e340\u0026nbsp;(57.43%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e378\u0026nbsp;(63.64%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e2.389\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.122\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eDiabetes\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e114\u0026nbsp;(19.26%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e154\u0026nbsp;(25.93%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e3.770\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.052\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eHyperlipemia\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e178\u0026nbsp;(30.07%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e212\u0026nbsp;(35.70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e2.124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.145\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eSmoking history\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e268\u0026nbsp;(45.27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e246\u0026nbsp;(41.41%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.969\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.325\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eCHD family history\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e74\u0026nbsp;(12.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e82\u0026nbsp;(13.80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.206\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.650\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLaboratory Index\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eCcr\u0026nbsp;(\u0026mu;mol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e71\u0026nbsp;(62,\u0026nbsp;81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e71\u0026nbsp;(59,\u0026nbsp;81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-0.505\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.613\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eUA\u0026nbsp;(\u0026mu;mol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e302\u0026nbsp;(251,\u0026nbsp;365)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e296\u0026nbsp;(254,\u0026nbsp;352)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-0.415\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.678\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eCK-MB\u0026nbsp;(U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e13\u0026nbsp;(11,\u0026nbsp;15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e13\u0026nbsp;(11,\u0026nbsp;15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-0.285\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.776\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003ePT\u0026nbsp;(s)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e12.90\u0026nbsp;(12.50,\u0026nbsp;13.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e12.80\u0026nbsp;(12.50,\u0026nbsp;13.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-1.643\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eINR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e0.97\u0026nbsp;(0.94,\u0026nbsp;1.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e0.96\u0026nbsp;(0.93,\u0026nbsp;1.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-1.426\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.154\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eFib\u0026nbsp;(g/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e3.12\u0026nbsp;(2.74,\u0026nbsp;3.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e3.13\u0026nbsp;(2.76,\u0026nbsp;3.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-0.479\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.632\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eD-dimer(\u0026micro;g/ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e0.26\u0026nbsp;(0.21,\u0026nbsp;0.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e0.26\u0026nbsp;(0.21,\u0026nbsp;0.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-0.267\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.789\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eHCY\u0026nbsp;(\u0026mu;mol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e12.50\u0026nbsp;(10.20,\u0026nbsp;14.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e11.80\u0026nbsp;(9.50,\u0026nbsp;15.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-1.323\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.186\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eH-CRP\u0026nbsp;(mg/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e1.07\u0026nbsp;(0.51,\u0026nbsp;2.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e1.20\u0026nbsp;(0.55,\u0026nbsp;3.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-1.614\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.107\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eLipoprotein-a\u0026nbsp;(nmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e25.45\u0026nbsp;(13.45,\u0026nbsp;58.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e24.10\u0026nbsp;(9.25,\u0026nbsp;57.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-1.698\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.090\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eTC\u0026nbsp;(mmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e4.31\u0026nbsp;(3.59,\u0026nbsp;5.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e4.35\u0026nbsp;(3.72,\u0026nbsp;5.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-0.517\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.605\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eTG\u0026nbsp;(mmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e1.46\u0026nbsp;(1.06,\u0026nbsp;2.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e1.53\u0026nbsp;(1.10,\u0026nbsp;2.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-0.832\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.406\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eLpA\u0026nbsp;(g/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e1.28\u0026nbsp;(1.11,\u0026nbsp;1.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e1.26\u0026nbsp;(1.14,\u0026nbsp;1.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-0.694\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.487\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eLpB\u0026nbsp;(g/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e0.98\u0026nbsp;(0.78,\u0026nbsp;1.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e0.97\u0026nbsp;(0.83,\u0026nbsp;1.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-0.276\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.783\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eHDL-c\u0026nbsp;(mmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e1.06\u0026nbsp;(0.90,\u0026nbsp;1.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e1.03\u0026nbsp;(0.87,\u0026nbsp;1.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-0.638\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.524\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eLDL-c\u0026nbsp;(mmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e2.78\u0026nbsp;(2.15,\u0026nbsp;3.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e2.83\u0026nbsp;(2.20,\u0026nbsp;3.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.984\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eFFA\u0026nbsp;(mmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e0.36\u0026nbsp;(0.25,\u0026nbsp;0.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e0.39\u0026nbsp;(0.26,\u0026nbsp;0.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-1028\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.304\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eLAAP\u0026nbsp;(mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e35\u0026nbsp;(33,\u0026nbsp;38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e36\u0026nbsp;(33,\u0026nbsp;39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-1.547\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.122\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eLVEDD\u0026nbsp;(mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e50\u0026nbsp;(48,\u0026nbsp;52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e49\u0026nbsp;(47,\u0026nbsp;52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-1.098\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.272\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eLVEF\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e62\u0026nbsp;(61,\u0026nbsp;65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e62\u0026nbsp;(60,\u0026nbsp;65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e-0.158\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.875\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eClassification of chest pain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.419\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.811\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.734513274336283%\" valign=\"top\"\u003e\n \u003cp\u003eTypical angina pectoris\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.13274336283186%\" valign=\"top\"\u003e\n \u003cp\u003e210\u0026nbsp;(35.47%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.24778761061947%\" valign=\"top\"\u003e\n \u003cp\u003e204 (34.34%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.884955752212388%\" colspan=\"3\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.58389261744966%\" valign=\"top\"\u003e\n \u003cp\u003eAtypical angina pectoris\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.767337807606264%\" valign=\"top\"\u003e\n \u003cp\u003e230\u0026nbsp;(38.85%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.648769574944073%\" valign=\"top\"\u003e\n \u003cp\u003e246\u0026nbsp;(41.41%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.58389261744966%\" valign=\"top\"\u003e\n \u003cp\u003eNonangina chest pain with electrocardiogram changes\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.767337807606264%\" valign=\"top\"\u003e\n \u003cp\u003e152\u0026nbsp;(25.68%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.648769574944073%\" valign=\"top\"\u003e\n \u003cp\u003e144\u0026nbsp;(24.24%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDegree of coronary artery disease\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eObstructive CAD\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e270\u0026nbsp;(45.61%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e266\u0026nbsp;(44.78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.840\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eSingle vessel disease\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e128\u0026nbsp;(21.62%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e114\u0026nbsp;(19.19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.539\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.463\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eDouble vessel disease\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e72\u0026nbsp;(12.16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e84\u0026nbsp;(14.14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.508\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.476\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eTriple vessel disease\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e70\u0026nbsp;(11.82%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e70\u0026nbsp;(11.78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.988\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eLeft Main Disease\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e22\u0026nbsp;(3.72%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e18\u0026nbsp;(3.03%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.214\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.644\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdverse reaction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eAllergy to contrast media\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e28\u0026nbsp;(4.73%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e16\u0026nbsp;(2.69%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1.720\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.190\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDrug use\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eAspirin\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e398\u0026nbsp;(67.23%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e410\u0026nbsp;(69.02%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.220\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.639\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eClopidogrel\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e224\u0026nbsp;(37.84%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e192\u0026nbsp;(32.32%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1.980\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.159\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eStatins\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e464\u0026nbsp;(78.38%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e452\u0026nbsp;(76.09%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.440\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.507\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026beta;-blocker\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e336\u0026nbsp;(56.76%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e342\u0026nbsp;(57.58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.840\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eACEI/ARB\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e198\u0026nbsp;(30.07%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e200\u0026nbsp;(33.67%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.886\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.347\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eTicagrelor\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e48\u0026nbsp;(8.11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e74\u0026nbsp;(12.46%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1.986\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.159\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.681978798586574%\" valign=\"top\"\u003e\n \u003cp\u003eCCB (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.08833922261484%\" valign=\"top\"\u003e\n \u003cp\u003e186\u0026nbsp;(31.42%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.204946996466433%\" valign=\"top\"\u003e\n \u003cp\u003e184\u0026nbsp;(30.98%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.54416961130742%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.480565371024735%\" valign=\"top\"\u003e\n \u003cp\u003e0.907\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData are presented as n (%) or M (P25, P75).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003cstrong\u003e.3\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePrimary clinical endpoints\u0026nbsp;\u003c/strong\u003eIn the CCTA group, ICA was performed in 292 of 592 patients to confirm the diagnosis of obstructive CAD, resulting in a 50.7% reduction in the use of ICA compared with the 100% rate (594/594) in the ICA group (P \u0026lt; 0.001) (Figure 2). In the CCTA group, 270 out of 292 patients who underwent ICA were ultimately diagnosed with obstructive CAD, and the percentage of patients with a nonessential ICA was 7.5%. In the ICA group, 266 of 594 patients underwent ICA, and the percentage of patients who underwent surgery via the nonessential ICA was 55.2% (P \u0026lt; 0.001) (Figure 3). In the CCTA group, 56 of 292 patients who underwent ICA did not undergo revascularization (including PCI and CABG), while in the ICA group 380 of 594 patients who underwent ICA did not undergo revascularization (19.2% vs. 64.0%, P \u0026lt; 0.001) (Figure 4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003cstrong\u003e.4\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eSecondary clinical endpoints\u0026nbsp;\u003c/strong\u003eThere was no significant difference in the MACE rate between the two groups. In the CCTA group, 18 patients were readmitted due to severe angina pectoris, among whom 8 patients underwent CCTA only during the first hospitalization; no obvious vascular stenosis was found at ICA upon readmission, and optimized drug therapy was administered. Six patients underwent ICA and stent implantation during the first hospitalization, no in-stent stenosis or significant stenosis of other vessels was found after ICA was readmitted, and optimized drug therapy was given. Two patients who did not undergo stenting after ICA during the first hospitalization were readmitted with stenting. Two patients underwent stent implantation during the first hospitalization, and ICA showed no stenosis in the stent upon readmission, while other vascular lesions progressed, and stent implantation was performed. In the ICA group, 8 patients were readmitted due to severe angina pectoris, 2 of whom underwent stent implantation during the first hospitalization, and ICA showed no stenosis in the stent upon readmission, while other vascular lesions progressed, and stent implantation was performed. Six patients underwent ICA and stent implantation during the first hospitalization, no in-stent stenosis or significant stenosis of other vessels was found after ICA was readmitted, and optimized drug therapy was started. There was no cardiac death, myocardial infarction, or stroke in the two groups during the 1-year follow-up, as shown in Table 2. Kaplan‒Meier curves were drawn to compare the MACE-free survival rate between the two groups during follow-up, which was 97.0% in the CCTA group and 98.7% in the ICA group. The log-rank test showed no significant difference (log-rank c\u0026sup2;=1.996, P=0.158), as shown in Figure 5. Contrast allergy occurred in 28 patients in the CCTA group and 16 patients in the ICA group (P \u0026gt; 0.190) (Table 1). The median hospitalization costs were 9194.61 yuan in the CCTA group and 10215.67 yuan in ICA group (P \u0026lt; 0.001) (Figure 6).\u003c/p\u003e\n\u003cp\u003eTable 2 MACE during follow-up\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.69138276553106%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.45691382765531%\" valign=\"top\"\u003e\n \u003cp\u003eCCTA group\u0026nbsp;(n＝592)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.851703406813627%\" valign=\"top\"\u003e\n \u003cp\u003eICA group\u0026nbsp;(n＝594)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.69138276553106%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMACE\u003c/strong\u003e (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.45691382765531%\" valign=\"top\"\u003e\n \u003cp\u003e18\u0026nbsp;(3.04%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.851703406813627%\" valign=\"top\"\u003e\n \u003cp\u003e8\u0026nbsp;(1.35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.69138276553106%\" valign=\"top\"\u003e\n \u003cp\u003eCardiac death\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.45691382765531%\" valign=\"top\"\u003e\n \u003cp\u003e0\u0026nbsp;(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.851703406813627%\" valign=\"top\"\u003e\n \u003cp\u003e0\u0026nbsp;(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.69138276553106%\" valign=\"top\"\u003e\n \u003cp\u003eMyocardial infarction\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.45691382765531%\" valign=\"top\"\u003e\n \u003cp\u003e0\u0026nbsp;(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.851703406813627%\" valign=\"top\"\u003e\n \u003cp\u003e0\u0026nbsp;(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.69138276553106%\" valign=\"top\"\u003e\n \u003cp\u003eStroke\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.45691382765531%\" valign=\"top\"\u003e\n \u003cp\u003e0\u0026nbsp;(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.851703406813627%\" valign=\"top\"\u003e\n \u003cp\u003e0\u0026nbsp;(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.69138276553106%\" valign=\"top\"\u003e\n \u003cp\u003eReadmission for severe angina\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.45691382765531%\" valign=\"top\"\u003e\n \u003cp\u003e18\u0026nbsp;(3.04%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.851703406813627%\" valign=\"top\"\u003e\n \u003cp\u003e8\u0026nbsp;(1.35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.69138276553106%\" valign=\"top\"\u003e\n \u003cp\u003eUnplanned revascularization\u0026nbsp;(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.45691382765531%\" valign=\"top\"\u003e\n \u003cp\u003e4\u0026nbsp;(0.68%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.851703406813627%\" valign=\"top\"\u003e\n \u003cp\u003e2\u0026nbsp;(0.34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp; The data in the table are presented as examples (%)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003cstrong\u003e.5\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eLogistic regression analysis\u0026nbsp;\u003c/strong\u003eThe forward selection method and the backward elimination method were combined for logistic regression. The baseline data of the patients included sex, age, history of hypertension, diabetes status, hyperlipidaemia status, smoking status, family history of CHD, creatinine, uric acid, creatine kinase\u0026ndash;myocardial band (CK-MB), prothrombin time, international normalized ratio (INR), fibrinogen quantification, D-dimer, homocysteine, hypersensitive CRP, free fatty acid, left atrial anterior and posterior diameter, left ventricular diastolic end diameter and left ventricular ejection fraction (LVEF); the variables with P\u0026lt;0.05 for predicting obstructive CAD were creatinine (OR = 1.027; 95% CI: 1.015-1.040; P\u0026lt; 0.001), age (OR＝1.030; 95% CI: 1.010-1.050; P＝0.003), physical activity or emotional agitation-induced symptoms (OR = 2.362; 95% CI: 1.010-1.050; P = 0.003), hyperlipidaemia (OR = 1.424; 95% CI: 1.128-1.714; P = 0.015), diabetes (OR = 1.793; 95% CI: 1.181-2.724; P = 0.006), and smoking history (OR = 1.785; 95% CI: 1.237-2.575; P = 0.002), as shown in table 3.\u003c/p\u003e\n\u003cp\u003eTable 3 Variables screened by logistic regression to predict obstructive CAD\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.20422535211268%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.070422535211268%\" valign=\"top\"\u003e\n \u003cp\u003eOR value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.056338028169016%\" valign=\"top\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.669014084507042%\" valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.20422535211268%\" valign=\"top\"\u003e\n \u003cp\u003eCcr\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.070422535211268%\" valign=\"top\"\u003e\n \u003cp\u003e1.027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.056338028169016%\" valign=\"top\"\u003e\n \u003cp\u003e1.015\u0026mdash;1.040\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.669014084507042%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.20422535211268%\" valign=\"top\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.070422535211268%\" valign=\"top\"\u003e\n \u003cp\u003e1.030\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.056338028169016%\" valign=\"top\"\u003e\n \u003cp\u003e1.010\u0026mdash;1.050\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.669014084507042%\" valign=\"top\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.20422535211268%\" valign=\"top\"\u003e\n \u003cp\u003eInduced by physical activity or emotional excitement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.070422535211268%\" valign=\"top\"\u003e\n \u003cp\u003e2.362\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.056338028169016%\" valign=\"top\"\u003e\n \u003cp\u003e1.663\u0026mdash;3.356\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.669014084507042%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.20422535211268%\" valign=\"top\"\u003e\n \u003cp\u003eHyperlipemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.070422535211268%\" valign=\"top\"\u003e\n \u003cp\u003e1.424\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.056338028169016%\" valign=\"top\"\u003e\n \u003cp\u003e1.128\u0026mdash;1.714\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.669014084507042%\" valign=\"top\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.20422535211268%\" valign=\"top\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.070422535211268%\" valign=\"top\"\u003e\n \u003cp\u003e1.793\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.056338028169016%\" valign=\"top\"\u003e\n \u003cp\u003e1.181\u0026mdash;2.724\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.669014084507042%\" valign=\"top\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.20422535211268%\" valign=\"top\"\u003e\n \u003cp\u003eSmoking history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.070422535211268%\" valign=\"top\"\u003e\n \u003cp\u003e1.785\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.056338028169016%\" valign=\"top\"\u003e\n \u003cp\u003e1.237\u0026mdash;2.575\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.669014084507042%\" valign=\"top\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003cstrong\u003e.6\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eEstablishment and validation of the obstructive CAD prediction model\u0026nbsp;\u003c/strong\u003eFrom the baseline data of patients in this study, variables that had clinical significance and statistical significance (P\u0026lt;0.05) were input as variables in the prediction model to establish a risk prediction model for obstructive CAD. According to the risk ratio of the variable in the regression analysis, the risk prediction score of obstructive CAD was established, and a line chart was drawn (Figure 7). The ROC curve was used to evaluate the predictive ability of the selected clinical indicators for obstructive CAD, and the AUC was 0.721, indicating that the model had a strong ability to distinguish patients at high or low risk of obstructive CAD in the selected population of this study (Figure 8).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eIn this study assessing the risks and benefits of noninvasive CCTA versus invasive ICA, patients with typical angina, atypical angina, and nonangina chest pain with electrocardiographic changes who were suspected to have CCS were randomly assigned to the CCTA group or ICA group. In the enrolled population, CCTA was shown to act as a \"safety gatekeeper\" for ICA, and using CCTA as a first-line test reduced nonessential ICA without increasing MACE. This study also confirmed that CCTA can reduce the cost of diagnostic evaluation in patients with stable chest pain. At the same time, the outpatient characteristics of CCTA can further shorten the diagnosis and treatment time of patients and reduce the waste of unnecessary medical resources. Patients are more willing to undergo the noninvasive CCTA.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Comparison with other relevant studies\u003c/h2\u003e \u003cp\u003eThe PROMISE study\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e and SCOT-HEART study\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e showed that CCTA, as a first-line examination for stable patients with suspected CHD, could detect a higher rate of obstructive CAD than other noninvasive diagnostic tests, including exercise ECG, nuclear stress tests and stress echocardiography, making the use of ICA more reasonable. The retrospective PLATFORM study\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e revealed that computed tomography-derived fractional flow reserve (CT-FFR) reduced the use of ICA by 61% and significantly reduced the proportion of patients with nonobstructive CAD on ICA. However, the present study did not assess the value of CCTA alone. A randomized single-centre study by Dewey et al. \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e reported that CCTA as a first-line test could significantly increase the rate of obstructive CAD caused by ICA, but the included population had atypical angina pectoris, with a prevalence of obstructive CAD of only 13%. In contrast, our study included patients with typical angina pectoris and nonangina chest pain with ECG changes, and the prevalence of obstructive CAD was 45.2%, expanding the scope of application of CCTA as a \"safety gatekeeper\" for ICA to some extent. The early study by Dewey et al.\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e randomized 340 patients, 168 of whom were assigned to CCTA and 172 to ICA. The primary clinical endpoint of the study was complications within 48 hours after CCTA or ICA, of which serious complications (including myocardial infarction, death, stroke, etc.) were uncommon (0.3%) and had similar rates in the two groups. However, complications such as haematoma at the puncture site and secondary bleeding at the puncture site were significantly less common in the CCTA group than in the ICA group. Our study compared the number of patients with contrast agent allergy in the CCTA group and the ICA group and found that there were more patients with contrast agent allergy in the CCTA group, but this difference was not significant. The reason may be that some patients in the CCTA group received two contrast agent injections in a short period of time, which may increase the likelihood of contrast agent allergy. In addition, Dewey et al\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e completed a 3.3-year (median) follow-up of 329 patients in the CCTA and ICA groups and found few MACE events: 7 of 167 patients in the CCTA group and 6 of 162 patients in the ICA group. This demonstrated that CCTA guidance alone was safe and did not increase long-term clinical events in patients who did not have ICA in the CCTA group, which was also confirmed in our study, but the follow-up time in our study was shorter, at 1 year. The CONSERVE study\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e also demonstrated that first-line use of CCTA can reduce unnecessary ICA examination, but in the CONSERVE study, 33.2% of the patients had\u0026thinsp;\u0026ge;\u0026thinsp;50% stenosis in either coronary artery, compared with 56.8% in our study. This suggests that our study evaluated the efficacy of CCTA in a population with a relatively higher risk of CHD. The CAT-CAD randomized single-centre study\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e, based on the 2013 European Society of Cardiology (ESC) guidelines for the management of stable CAD, included patients with an ICA indication, including patients with typical angina with a left ventricular ejection fraction\u0026thinsp;\u0026lt;\u0026thinsp;50%, patients with PTP between 50% and 80% with a positive or inconclusive functional test, and patients with PTP\u0026thinsp;\u0026gt;\u0026thinsp;85%. PTP was assessed based on criteria for age, sex, and angina symptoms. The CAT-CAD study\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e showed that the use of CCTA as a first-line test reduced the number of patients with ICA by 64.4% and the number of non-revascularization patients after ICA by 88.1% compared to those who underwent ICA. However, that study included only 120 patients in total and 45 patients with typical angina. The DISCHARGE trial\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e was a randomized controlled study comparing CCTA and ICA as initial tests in 3561 patients with stable chest pain and a moderate predictive probability of CHD. At 3.5 years of follow-up, there was no substantial difference between the CCTA and ICA groups in the incidence of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke, and the incidence of MACE was very low, at 2.1% for CCTA and 3.0% for ICA. There was also no difference in the incidence of angina during follow-up. These results are similar to our conclusion. However, the proportion of patients enrolled in the DISCHARGE trial who had at least 50% stenosis in any coronary artery was 25.7%, compared with 56.8% in our study, and the patients enrolled in our study were at higher risk for obstructive CAD.\u003c/p\u003e \u003cp\u003e\u003cb\u003e4.2 Limitations and prospects\u003c/b\u003e This study was conducted at a single centre, and patients were not enrolled on consecutive working days, which could introduce some bias. Second, this study chose nonessential ICA rather than MACE as the primary endpoint because the MACE rate was very low in the study population. A much larger sample will be needed for future studies. In addition, the MACE follow-up in this study only ran for 1 year, so longer follow-up will be needed to test the results of this study. Third, due to the small sample size, this study was unable to provide a robust assessment of the clinical complications associated with the two examinations. Fourth, patients with impaired renal function were excluded. One study showed that intravenous iodine contrast agents are less risky than arterial iodine injections\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e, which supports the better safety profile of CCTA. Fifth, the sample was relatively small for establishing a predictive model for obstructive CAD. Future studies can develop a risk score model for obstructive CAD with stronger predictive power based on a larger sample size.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eIn patients with suspected CCS, including typical angina, atypical angina and nonangina chest pain with abnormal electrocardiogram results, the use of CCTA as a first-line diagnostic test can reduce the unnecessary incidence of ICA and hospitalization costs without increasing the incidence of MACE. A risk prediction model of obstructive CAD was established based on the baseline data of the patients enrolled in this study, providing a clinical basis for the decision to use CCTA or ICA. Patients with a low probability of obstructive CAD can be given priority for CCTA, while patients with a high probability can be given priority for ICA.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the local ethics committee of TEDA International Cardiovascular Hospital. All experiments were performed in accordance with relevant guidelines and regulations such as the Declaration of Helsinki and the patients signed the informed consent form and agreed to be published.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed in the present study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunded by Tianjin Key Medical Discipline (Specialty) Construction Project (TJYXZDXK-020A).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical data\u0026nbsp;collection and analysis were performed by\u0026nbsp;HL\u0026nbsp;and\u0026nbsp;RJF.\u0026nbsp;CTCA imaging data was collected and analyzed by WZ.\u0026nbsp;The first draft of the manuscript was written by\u0026nbsp;LXD,\u0026nbsp;and all authors commented on previous versions of the manuscript.\u0026nbsp;LXD and RJF also did the statistics work. RJ\u0026nbsp;contributed to the study conception and design.\u0026nbsp;All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eCorresponding author: Correspondence to Rui Jing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmerican Journal Experts part of Springer Nature did some work for the English polishing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKnuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes [J]. Eur Heart J. 2020;41(3):407\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCollet JP, Thiele H, Barbato E, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation [J]. Eur Heart J. 2021;42(14):1289\u0026ndash;367.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIbanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC) [J]. Eur Heart J. 2018;39(2):119\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNarula J, Chandrashekhar Y, Ahmadi A, et al. SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography: A Report of the Society of Cardiovascular Computed Tomography [J]. J Cardiovasc Comput Tomogr. 2021;15(3):192\u0026ndash;217.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTask Force M, Montalescot G, Sechtem U, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology [J]. Eur Heart J. 2013;34(38):2949\u0026ndash;3003.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel MR, Peterson ED, Dai D, et al. Low diagnostic yield of elective coronary angiography [J]. N Engl J Med. 2010;362(10):886\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoschovitis A, Cook S, Meier B. Percutaneous coronary interventions in Europe in 2006 [J]. EuroIntervention. 2010;6(2):189\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevenson B, Albrecht A, Gohring S, et al. [6th report of the German Association of Cardiologists in private practice (BNK) on quality assurance in cardiac catheterization and coronary intervention 2006\u0026ndash;2009] [J]. Herz. 2011;36(1):41\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchuetz GM, Schlattmann P, Dewey M. Use of 3x2 tables with an intention to diagnose approach to assess clinical performance of diagnostic tests: meta-analytical evaluation of coronary CT angiography studies [J]. BMJ. 2012;345:e6717.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBudoff MJ, Kalia N, Cole J, et al. Diagnostic accuracy of Visipaque enhanced coronary computed tomographic angiography: a prospective multicenter trial [J]. Coron Artery Dis. 2017;28(1):52\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBudoff MJ, Li D, Kazerooni EA, et al. Diagnostic Accuracy of Noninvasive 64-row Computed Tomographic Coronary Angiography (CCTA) Compared with Myocardial Perfusion Imaging (MPI): The PICTURE Study, A Prospective Multicenter Trial [J]. Acad Radiol. 2017;24(1):22\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeglia D, Rovai D, Caselli C et al. Detection of significant coronary artery disease by noninvasive anatomical and functional imaging [J]. Circ Cardiovasc Imaging, 2015, 8(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMancini GBJ, Leipsic J, Budoff MJ, et al. CT Angiography Followed by Invasive Angiography in Patients With Moderate or Severe Ischemia-Insights From the ISCHEMIA Trial [J]. JACC Cardiovasc Imaging. 2021;14(7):1384\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTonino PA, Fearon WF, De Bruyne B, et al. Angiographic versus functional severity of coronary artery stenoses in the FAME study fractional flow reserve versus angiography in multivessel evaluation [J]. J Am Coll Cardiol. 2010;55(25):2816\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarwick TH, Cho I. Finding the Gatekeeper to the Cardiac Catheterization Laboratory: Coronary CT Angiography or Stress Testing? [J]. J Am Coll Cardiol. 2015;65(25):2747\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDouglas PS, Hoffmann U, Patel MR, et al. Outcomes of anatomical versus functional testing for coronary artery disease [J]. N Engl J Med. 2015;372(14):1291\u0026ndash;300.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003einvestigators S-H. CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicentre trial [J]. Lancet, 2015, 385(9985): 2383\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDouglas PS, Pontone G, Hlatky MA, et al. Clinical outcomes of fractional flow reserve by computed tomographic angiography-guided diagnostic strategies vs. usual care in patients with suspected coronary artery disease: the prospective longitudinal trial of FFR(CT): outcome and resource impacts study [J]. Eur Heart J. 2015;36(47):3359\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDewey M, Rief M, Martus P, et al. Evaluation of computed tomography in patients with atypical angina or chest pain clinically referred for invasive coronary angiography: randomised controlled trial [J]. BMJ. 2016;355:i5441.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang HJ, Lin FY, Gebow D, et al. Selective Referral Using CCTA Versus Direct Referral for Individuals Referred to Invasive Coronary Angiography for Suspected CAD: A Randomized, Controlled, Open-Label Trial [J]. JACC Cardiovasc Imaging. 2019;12(7 Pt 2):1303\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRudzinski PN, Kruk M, Kepka C, et al. The value of Coronary Artery computed Tomography as the first-line anatomical test for stable patients with indications for invasive angiography due to suspected Coronary Artery Disease: CAT-CAD randomized trial [J]. J Cardiovasc Comput Tomogr. 2018;12(6):472\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGroup DT, Maurovich-Horvat P, Bosserdt M et al. CT or Invasive Coronary Angiography in Stable Chest Pain [J]. N Engl J Med, 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWichmann JL, Katzberg RW, Litwin SE, et al. Contrast-Induced Nephrop [J] Circulation. 2015;132(20):1931\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"invasive coronary angiography, coronary computed tomographic angiography, chronic coronary syndrome, obstructive coronary artery disease, major adverse cardiovascular events, unnecessary ICA rate","lastPublishedDoi":"10.21203/rs.3.rs-4597914/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4597914/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The advantages and disadvantages of direct invasive coronary angiography (ICA) and coronary computed tomographic angiography (CCTA)+ICA were compared in patients with suspected chronic coronary syndrome (CCS) who presented with angina symptoms or who had nonangina chest pain with abnormal electrocardiogram results.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A total of 1200 patients who met the inclusion criteria at TEDA International Cardiovascular Hospital from January 2021 to December 2022 were randomly divided into two groups at a 1:1 ratio: CCTA+ICA strategy (CCTA group) and direct ICA strategy (ICA group). All patients in the CCTA group underwent CCTA examination first. If these results showed positive obstructive coronary artery disease (CAD), then typical angina with coronary artery stenosis ranging from 50% to 70% or vascular segments could not be analysed due to severe calcification, so ICA was further performed for definitive diagnosis, and ICA results were taken as the final diagnosis. All patients in ICA group underwent ICA examination directly. Demographic data, cardiovascular risk factors, biochemical criteria, chest pain classification, coronary vessel lesion severity and drug use in the two groups were compared. All patients were followed for 1 year after discharge to observe major adverse cardiovascular events (MACE). The differences in unnecessary ICA rate, 1-year MACE, allergic reaction to contrast agent and hospitalization cost between the two groups were analysed. Based on the baseline clinical data of patients included in this study, a risk prediction model for obstructive CAD was established by logistic regression.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003e(1) There were 592 patients in the CCTA group and 594 patients in ICA group. The percentage of unnecessary ICA procedures was 7.5% in the CCTA group and 55.2% in ICA group (P\u0026lt; 0.001). (2) Fifty-one patients in the CCTA group were readmitted for severe angina, 4 of whom underwent unplanned percutaneous coronary intervention (PCI). Eight patients in the ICA group were readmitted for severe angina, 2 of whom underwent unplanned PCI. There were no cardiac deaths, nonfatal myocardial infarctions or strokes in either group over 1-year follow-up. There was no statistically significant difference in the rates of MACE-free survival between the two groups (97.0% vs. 98.7%, log-rankc²=1.996, P=0.158). (3) Allergic reaction to cotrast was observed in 28 patients in the CCTA group and 16 in the ICA group (P＝0.190). (4) The median hospitalization cost in the CCTA group was 9194.61 yuan, and that in the ICA group was 10215.67 yuan, a significant difference. (5) Based on the combination of the logistic regression forward selection method and backward elimination method, variables with P\u0026lt;0.05 were selected from the baseline data of patients to predict obstructive CAD, including creatinine, age, physical activity or emotionally induced symptoms, hyperlipidaemia, diabetes and smoking history. The above variables were used to establish a risk prediction model for obstructive CAD. The area under the ROC curve (AUC) of this model was 0.721, indicating good predictive ability.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eIn patients with suspected CCS, including typical angina, atypical angina and nonangina chest pain with abnormal electrocardiogram results, the use of CCTA as a first-line diagnostic test can reduce the unnecessary incidence of ICA and hospitalization costs without increasing the incidence of MACE. A risk prediction model of obstructive CAD was established based on the baseline data of the patients enrolled in this study, providing a clinical basis for the decision to use CCTA or ICA. Patients with a low probability of obstructive CAD can be given priority for CCTA, while patients with a high probability can be given priority for ICA.\u003c/p\u003e","manuscriptTitle":"Evaluation of the clinical value of CCTA as the preferred screening method in patients with chronic coronary syndrome","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 20:58:55","doi":"10.21203/rs.3.rs-4597914/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-27T16:53:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-27T00:38:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-22T19:24:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"73654851669661628589676612442712744662","date":"2025-01-22T19:09:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"337359798318678103980607253454867606358","date":"2025-01-21T23:08:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-21T21:39:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"110058211808190477606541379301966545400","date":"2025-01-21T20:43:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"95401716433122939139971047689763866162","date":"2025-01-21T18:12:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"121293620080627549006508144044355763066","date":"2025-01-21T17:54:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-18T22:06:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"331308718698046010530472481817454232847","date":"2025-01-08T19:45:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-16T10:34:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-06-26T09:22:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-24T12:41:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-24T12:41:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cardiovascular Disorders","date":"2024-06-18T06:54:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"785c57e6-b512-473e-9869-744437600b20","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-03T16:05:20+00:00","versionOfRecord":{"articleIdentity":"rs-4597914","link":"https://doi.org/10.1186/s12872-025-04587-x","journal":{"identity":"bmc-cardiovascular-disorders","isVorOnly":false,"title":"BMC Cardiovascular Disorders"},"publishedOn":"2025-02-25 15:57:55","publishedOnDateReadable":"February 25th, 2025"},"versionCreatedAt":"2024-07-18 20:58:55","video":"","vorDoi":"10.1186/s12872-025-04587-x","vorDoiUrl":"https://doi.org/10.1186/s12872-025-04587-x","workflowStages":[]},"version":"v1","identity":"rs-4597914","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4597914","identity":"rs-4597914","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}