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JAMA Intern Med. 2018 Feb 1;178(2):239-247. doi: 10.1001/jamainternmed.2017.7821.

Comparison of Physician Visual Assessment With Quantitative Coronary Angiography in Assessment of Stenosis Severity in China.

Author information

National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease and Division of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
Yale University School of Medicine, New Haven, Connecticut, United States.
Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.
Ann Arbor VA Center for Clinical Management and Research and University of Michigan Health System, Ann Arbor, Michigan.
Yale University Medical Center, New Haven, Connecticut.
Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri.
Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States.
Section of Cardiovascular Medicine and Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.
Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China.
Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut.



Although physician visual assessment (PVA) of stenosis severity is a standard clinical practice to support decisions for coronary revascularization, there are concerns about its accuracy.


To compare PVA with quantitative coronary angiography (QCA) as a means of assessing stenosis severity among patients undergoing percutaneous coronary intervention (PCI) in China.

Design, Setting, and Participants:

A cross-sectional study (2012-2013) of a random subset of 1295 patients from the China Patient-centered Evaluative Assessment of Cardiac Events (PEACE) Prospective PCI Study was carried out. The PEACE Prospective PCI study recruited a consecutive sample of patients undergoing PCI at 35 hospitals in 18 provinces of China. The coronary angiograms of this subset of participants were reviewed using QCA by 2 independent core laboratories blinded to PVA readings.

Main Outcomes and Measures:

Differences between PVA and QCA assessments of stenosis severity for lesions for which PCI was performed and variation of these differences among hospitals and physicians, stratified by the diagnosis of acute myocardial infarction (AMI).


In patients without AMI, the mean (SD) age was 62 (10) years, and 217 (31.5%) were women; in patients with AMI, the mean (SD) age was 60 (11) years, and 153 (25.2%) were women. The mean (SD) percent diameter stenosis by PVA was 16.0% (11.5%) greater than that by QCA in patients without AMI and 10.2% (12.3%) in those with AMI (Pā€‰<ā€‰.001 for both comparisons). In patients without AMI, of 837 lesions with 70% or more stenosis by PVA, 427 (50.6%) were less than 70% by QCA; in patients with AMI, similar patterns were observed to a lesser extent. Among patients without AMI, only 4 (0.47%) lesions were additionally assessed with fractional flow reserve. Among 30 hospitals, the difference between PVA and QCA readings of stenosis severity varied from 7.6% (95% CI, 0.4%-14.7%) to 21.3% (95% CI, 17.1%-24.9%) among non-AMI patients. Across 57 physicians, this difference varied from 6.9% (95% CI, -1.4%-15.3%) to 26.4% (95% CI, 21.5%-31.4%).

Conclusions and Relevance:

For coronary lesions treated with PCI in China, PVA reported substantially higher readings of stenosis severity than QCA, with large variation across hospitals and physicians. These findings highlight the need to improve the accuracy of information used to guide treatment decisions in catheterization laboratories.

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