What is the management approach for patients with multivessel coronary artery disease (CAD) incidentally noted on a computed tomography (CT) scan?

Management of Multivessel Coronary Artery Disease Incidentally Noted on CT Scan

For patients with multivessel coronary artery disease incidentally discovered on CT scan, a risk-stratification approach should be implemented with consideration for invasive coronary angiography for those with high-risk features, while initiating aggressive medical therapy for all patients. 1

Initial Assessment and Risk Stratification

• Classify the severity of coronary artery disease using the CAD-RADS classification system to guide management decisions 1
• Assess for high-risk features including:
  • Left main stenosis ≥50% or three-vessel obstructive disease (>70%) (CAD-RADS 4B) 1
  • Very high-grade stenosis (>90%) 1
  • High-risk plaque features 1
  • Left ventricular dysfunction (LVEF <40%) 1
• Consider early echocardiography to identify significant left ventricular dysfunction, as patients with multivessel disease and LV dysfunction are at high risk and could benefit from CABG 1

Management Algorithm Based on CAD-RADS Classification

For CAD-RADS 4A (Severe stenosis 70-99% in one or two vessels):

• Initiate guideline-directed medical therapy (GDMT) including aggressive risk factor modification and preventive pharmacotherapy 1
• Consider functional assessment to evaluate for ischemia using one of the following:
  • CT-derived fractional flow reserve (CT-FFR) 1
  • CT myocardial perfusion imaging (CTP) 1
  • Stress testing (exercise ECG, stress echocardiography, SPECT, PET, or cardiac MRI) 1
• Invasive coronary angiography (ICA) is recommended if:
  • Very high-grade stenosis (>90%) is present 1
  • High-risk plaque features are identified 1
  • Evidence of lesion-specific ischemia is found on functional testing 1
  • Patient has persistent symptoms despite optimal medical therapy 1

For CAD-RADS 4B (Left main stenosis ≥50% or three-vessel obstructive disease >70%):

• Invasive coronary angiography (ICA) is strongly recommended due to high-risk anatomy 1, 2
• Initiate aggressive medical therapy while planning for invasive assessment 1

Revascularization Considerations

• For patients with multivessel disease and left ventricular dysfunction, CABG may provide a survival benefit 1, 2
• The decision between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) should be based on coronary anatomy complexity, left ventricular function, and comorbidities 2, 3
• For single-vessel disease, PCI with stenting of the culprit lesion is typically the first choice 2, 3

Medical Therapy

• All patients should receive guideline-directed medical therapy regardless of revascularization strategy 1, 3
• Medical therapy includes:
  • Antiplatelet therapy (aspirin) 1
  • Lipid-lowering therapy 1
  • Blood pressure control 1
  • Diabetes management if applicable 1
  • Lifestyle modifications 1

Special Considerations

• For asymptomatic patients with multivessel CAD, the benefit of revascularization should be carefully weighed against the risks 1, 4
• The ISCHEMIA trial demonstrated similar outcomes between initial conservative and invasive strategies for stable ischemic heart disease, highlighting the importance of optimal medical therapy 1, 4
• Patients with acute coronary syndrome and multivessel disease may benefit from complete revascularization, though the optimal timing remains under investigation 5

Follow-up Recommendations

• Regular clinical follow-up to assess for development of symptoms 1
• Consider periodic functional testing to assess for progression of ischemia 1
• Continued risk factor modification and adherence to medical therapy 1

Common Pitfalls to Avoid

• Underestimating the significance of multivessel disease in asymptomatic patients 1
• Failing to assess left ventricular function, which is crucial for risk stratification 1
• Delaying invasive assessment in patients with high-risk features (left main disease, three-vessel disease, or LV dysfunction) 1
• Neglecting optimal medical therapy, which is essential regardless of revascularization strategy 1, 4