Lin MuFollow

Date of Award

January 2020

Document Type


Degree Name

Medical Doctor (MD)



First Advisor

Harlan M. Krumholz


Inaccuracy in physician visual assessment (PVA) of stenosis severity may bias interventional decisions for coronary revascularization. This pragmatic study compares PVA in routine clinical practice with quantitative coronary angiography (QCA) as a means of assessing stenosis severity in China. We hypothesize that clinically meaningful differences exist between PVA and QCA in determining stenosis severity.

We randomly selected 1,295 participants from a prospective study of percutaneous coronary intervention (PCI) between 2012 and 2013 in 18 Chinese provinces and compared interpretations of their coronary angiograms by PVA and QCA, where QCA was performed by core laboratories blinded to PVA readings. We examined the differences between PVA and QCA assessments of stenosis severity for lesions for which PCI was performed and the variation of these differences among hospitals and physicians, stratified by the diagnosis of acute myocardial infarction (AMI).

The mean percent stenosis by PVA was 16.0% (SD, 11.5%; P<0.001) greater than that by QCA in non-AMI patients and 10.2% (SD, 12.3%; P<0.001) in AMI patients. In non-AMI patients, of the 837 lesions with 70% or more stenosis by PVA, 427 (50.6%) were less than 70% by QCA, and only 4 (0.47%) lesions were assessed with fractional flow reserve. The difference between PVA and QCA assessments of stenosis severity in non-AMI patients varied from 7.6% (95% CI, 0.4–14.7%) to 21.3% (95% CI, 17.1–24.9%) across hospitals (N=30) and from 6.9% (95% CI, -1.4–15.3%) to 26.4% (95% CI, 21.5–31.4%) across physicians (N=57).

PVA overestimated stenosis severity with variation across hospitals and physicians in China. These findings highlight the need to improve the accuracy of information used to guide treatment decisions in catheterization laboratories.


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