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Early computed tomography coronary angiography in patients with suspected acute coronary syndrome: randomised
Alasdair J Gray1,2, Carl Roobottom3,4, Jason E Smith3
1University of Edinburgh, Edinburgh, UK alasdair.gray@ed.ac.uk.
Insights
Early computed tomography (CT) coronary angiography in intermediate-risk patients with chest pain did not improve one-year outcomes. While reducing invasive angiography, it did not alter overall treatment or clinical events, suggesting it is not routinely recommended.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Clinical Trials
Background:
- Acute chest pain is a common emergency department presentation.
- Intermediate-risk patients require careful evaluation for acute coronary syndrome (ACS).
- Early computed tomography (CT) coronary angiography is a potential diagnostic tool.
Purpose of the Study:
- To determine if early CT coronary angiography improves one-year clinical outcomes in intermediate-risk acute chest pain patients.
- To assess the impact of early CT coronary angiography on major adverse cardiac events and interventions.
Main Methods:
- A randomized controlled trial involving 1748 adult participants across 37 UK hospitals.
- Participants with suspected ACS and intermediate risk factors were randomized to early CT coronary angiography or standard care.
- The primary endpoint was all-cause death or myocardial infarction at one year.
Main Results:
- No significant difference in the primary endpoint between early CT coronary angiography (5.8%) and standard care (6.1%) groups (P=0.65).
- Early CT coronary angiography significantly reduced invasive coronary angiography rates (54.0% vs. 60.8%, P=0.001).
- No differences in coronary revascularization or ACS treatment were observed; hospital stay was slightly longer with early CT.
Conclusions:
- Early CT coronary angiography did not improve one-year clinical outcomes or alter overall coronary interventions in intermediate-risk chest pain patients.
- The procedure reduced invasive angiography rates but modestly increased hospital stay.
- Routine use of early CT coronary angiography is not supported in this patient population.
Objectives:
To establish if the use of early computed tomography (CT) coronary angiography improves one year clinical outcomes in patients presenting to the emergency department with acute chest pain and at intermediate risk of acute coronary syndrome and subsequent clinical events.
Design:
Randomised controlled trial.
Setting:
37 hospitals in the UK.
Participants:
Adults with suspected or a provisional diagnosis of acute coronary syndrome and one or more of previous coronary heart disease, raised levels of cardiac troponin, or abnormal electrocardiogram.
Interventions:
Early CT coronary angiography and standard of care compared with standard of care only.
Main Outcome Measures:
Primary endpoint was all cause death or subsequent type 1 or 4b myocardial infarction at one year.
Results:
Between 23 March 2015 and 27 June 2019, 1748 participants (mean age 62 years (standard deviation 13), 64% men, mean global registry of acute coronary events (GRACE) score 115 (standard deviation 35)) were randomised to receive early CT coronary angiography (n=877) or standard of care only (n=871). Median time from randomisation to CT coronary angiography was 4.2 (interquartile range 1.6-21.6) hours. The primary endpoint occurred in 51 (5.8%) participants randomised to CT coronary angiography and 53 (6.1%) participants who received standard of care only (adjusted hazard ratio 0.91 (95% confidence interval 0.62 to 1.35), P=0.65). Invasive coronary angiography was performed in 474 (54.0%) participants randomised to CT coronary angiography and 530 (60.8%) participants who received standard of care only (adjusted hazard ratio 0.81 (0.72 to 0.92), P=0.001). There were no overall differences in coronary revascularisation, use of drug treatment for acute coronary syndrome, or subsequent preventive treatments between the two groups. Early CT coronary angiography was associated with a slightly longer time in hospital (median increase 0.21 (95% confidence interval 0.05 to 0.40) days from a median hospital stay of 2.0 to 2.2 days).
Conclusions:
In intermediate risk patients with acute chest pain and suspected acute coronary syndrome, early CT coronary angiography did not alter overall coronary therapeutic interventions or one year clinical outcomes, but reduced rates of invasive angiography while modestly increasing length of hospital stay. These findings do not support the routine use of early CT coronary angiography in intermediate risk patients with acute chest pain and suspected acute coronary syndrome.
Trial Registration:
ISRCTN19102565, NCT02284191.
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