Physician visual assessment of coronary stenosis severity overestimates quantitative coronary angiography

1. On average, in this cross-sectional study, physician visual assessment overestimated coronary stenosis severity as compared to quantitative coronary angiography.

2. There was wide variation across hospitals and physicians when comparing severity of coronary stenosis.

Evidence Rating Level: 3 (Average)

Study Rundown: The presence and severity of coronary stenosis is determined by coronary angiography. This is all done through physician visual assessment (PVA). While determining the presence of coronary stenosis may be easier with PVA, it is unclear how PVA performs in determining accurate severity of stenosis. This cross-sectional study aimed to compare PVA with quantitative coronary angiography (QCA) in assessing stenosis severity among patients undergoing percutaneous coronary intervention (PCI) in China.

There was large variation across hospitals and physicians when comparing determination of severity of coronary stenosis by PVA or QCA. On average, PVA over-estimated stenosis severity by 16% in patients without acute myocardial infarction (AMI) and 10% in those with AMI. Strengths of this study include its large sample size across many hospitals however limitations of this study include its cross-sectional design and the fact that it was only performed in China, and thus generalizability to North American physicians may be limited.

Click to read the study, published in JAMA Internal Medicine

Relevant Reading: Coronary Catheterization and Percutaneous Coronary Intervention in China 10-Year Results From the China PEACE-Retrospective CathPCI Study

In-Depth [cross-sectional]: This cross-sectional study took place during 2012-2013 and included a random subset of 1295 patients form the China Patient-centred Evaluative Assessment of Cardiac Events (PEACE) Prospective PCI study. The PEACE prospective PCI study included patients undergoing PCI across 35 hospitals in 18 provinces of China. Coronary stenosis severity was determined by PVA and QCA. Two independent core laboratories that were blinded to PVA readings did the QCA assessments. The outcome of interest was differences between the PVA and QCA assessments of coronary stenosis severity in lesions that PCI was performed and were stratified by the presence or absence of a diagnosis of AMI. Hospital and physician variability was also assessed.

Patients in the study were similarly aged regardless of AMI diagnosis. On average, PVA overestimated coronary stenosis severity as compared to QCA in both patients with AMI and without AMI. In those with AMI, PVA coronary stenosis severity was mean (SD) 10.2% (12.3%) greater than QCA and in those without AMI, PVA coronary stenosis severity was 16.0% (11.5%) greater than QCA. Both differences were statistically different with p < 0.001. The differences between PVA and QCA across the 30 hospitals varied from 7.6% (95% CI 0.4%-14.7%) to 21.3% (95% CI 17.1%-24.9%). Physician variation ranged from 6.7% (95% CI -1.4%-15.3%) to 26.4% (95% CI 21.5%-31.4%).

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