EVINCI: Invasive Diagnostic Tests Can Be Dramatically Reduced

June 29, 2012

June 29, 2012 (Madrid, Spain)Better use of noninvasive screening tests for patients with chest pain could avoid up to 75% of costly invasive procedures, according to preliminary results of the Evaluation of Integrated Cardiac Imaging (EVINCI) study [1].

The study was organized by the European Society of Cardiology (ESC) Working Group on Nuclear Cardiology and Cardiac CT, which explains that most patients with suspected coronary disease undergo invasive procedures such as angiography without first having preliminary effective noninvasive screening. But obstructive coronary disease is found to be present in less than 40% of patients undergoing invasive coronary angiography, highlighting the need for better selection of high-risk patients by noninvasive means to avoid costly, risky, and inappropriate invasive procedures.

The three-year multicenter European EVINCI trial was therefore conducted to try to define the most cost-effective strategy for diagnosing patients with suspected coronary artery disease.

The EVINCI study enrolled 695 patients with chronic chest pain and a 60% average probability of having coronary artery disease. Patients were aged 30 to 75 years, and 38% were female. They all underwent a variety of noninvasive imaging tests, including multislice computed tomography (CT), echocardiography, single-photon-emission computed tomography (SPECT), or MRI. They all also underwent invasive tests--coronary angiography and functional tests--as a reference method to define the presence, extent, and functional relevance of coronary disease. And the results of the various tests were compared by a central core lab. The different noninvasive strategies were compared for their diagnostic accuracy, and the costs and potential risks were monitored.

Preliminary results suggest that heart disease can be diagnosed in the majority of cases without needing a catheterization and that many patients with chest pain receive unnecessary invasive procedures.

One of the cardiologists leading the study, Dr Jose Zamorano (University Hospital Ramón y Cajal, Madrid, Spain), commented to heartwire : "In general, about 70% of the time, the noninvasive test gave the same result as the angiography, so invasive procedures could be avoided."

He added: "The study has now closed, but additional analyses are ongoing as to which noninvasive tests give the best results in which group of patients. We are looking at different ages, genders, and disease states. We need to see in detail which test is most appropriate for each individual. Results of these analyses will be presented later this year."

CHD Prevalence Less Than Expected

The other major conclusion from the study is that the presence of ischemic heart disease is less than expected. Zamorano noted: "Data in the past have come from retrospective studies, but our results are better, as this is a prospective study. And we found that only about 25% of patients with chest pain were actually established to have coronary heart disease. We were expecting the number to be more like 60%."

Coinvestigator Dr Danilo Neglia (CNR Institute of Clinical Physiology, Pisa, Italy) is quoted in an ESC press release as saying: "We do actually know the strengths and weaknesses of [each of the noninvasive tests selected], but there is no clue as to which approach is the most cost-effective to solve the diagnostic issue and define proper treatment in the single patient." To this end, noninvasive imaging tests were chosen that would assess both coronary anatomic abnormalities and their functional effects. In each patient, coronary anatomy was assessed using multislice CT. Radionuclide imaging (either SPECT or positron-emission tomography [PET]) was used to measure myocardial perfusion at rest and during stress. The effects of myocardial ischemia on ventricular function were assessed by either MRI or echocardiography during stress.

The press release adds that the EVINCI study results should reduce the use of inappropriate invasive procedures and related costs, reduce risks for patients, and enable patients who are truly at risk to be effectively treated.

Costs, potential risks of each procedure, and patients' perception of health status are also being evaluated in a health economic analysis comparing each diagnostic strategy.

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