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Early computed tomography coronary angiography in adults presenting with suspected acute coronary syndrome: the
Alasdair J Gray1,2, Carl Roobottom3, Jason E Smith4
1Usher Institute, University of Edinburgh, Edinburgh, UK.
Insights
Early computed tomography coronary angiography did not improve 1-year outcomes for acute coronary syndrome patients but increased hospital stays and costs. Routine use in intermediate-risk patients is not supported by these findings.
Area of Science:
- Cardiology
- Medical Imaging
- Clinical Trials
Background:
- Acute coronary syndrome (ACS) is a critical medical emergency.
- Optimal investigation strategies for intermediate-risk ACS patients remain unclear.
- Early computed tomography coronary angiography (CTCA) is being explored as a diagnostic tool.
Purpose of the Study:
- To evaluate the effectiveness of early CTCA in diagnosing and managing adults with suspected ACS.
- To compare clinical outcomes and cost-effectiveness of early CTCA versus standard care.
Main Methods:
- A prospective, multicentre, randomised controlled trial involving 1748 adults with suspected ACS.
- Participants received either early CTCA plus standard care or standard care alone.
- Primary endpoint was 1-year all-cause death or myocardial infarction; secondary outcomes included interventions and costs.
Main Results:
- No significant difference in the primary endpoint between early CTCA and standard care groups (5.8% vs 6.1%).
- Early CTCA reduced invasive coronary angiography use (p=0.001) but did not change revascularisation or other therapies.
- Early CTCA was associated with longer hospital stays and higher healthcare costs (£561 per patient).
Conclusions:
- Early CTCA did not alter 1-year clinical outcomes or overall therapeutic interventions in suspected ACS patients.
- The procedure increased hospitalisation duration and healthcare expenditure.
- Findings do not support routine early CTCA for intermediate-risk ACS patients.
Background:
Acute coronary syndrome is a common medical emergency. The optimal strategy to investigate patients who are at intermediate risk of acute coronary syndrome has not been fully determined.
Objective:
To investigate the role of early computed tomography coronary angiography in the investigation and treatment of adults presenting with suspected acute coronary syndrome.
Design:
A prospective, multicentre, open, parallel-group randomised controlled trial with blinded end-point adjudication.
Setting:
Thirty-seven hospitals in the UK.
Participants:
Adults (aged ≥ 18 years) presenting to the emergency department, acute medicine services or cardiology department with suspected or provisionally diagnosed acute coronary syndrome and at least one of the following: (1) a prior history of coronary artery disease, (2) a cardiac troponin level > 99th centile and (3) an abnormal 12-lead electrocardiogram.
Interventions:
Early computed tomography coronary angiography in addition to standard care was compared with standard care alone. Participants were followed up for 1 year.
Main Outcome Measure:
One-year all-cause death or subsequent type 1 (spontaneous) or type 4b (stent thrombosis) myocardial infarction, measured as the time to such event adjudicated by two cardiologists blinded to the computerised tomography coronary angiography ( CTCA ) arm. Cost-effectiveness was estimated as the lifetime incremental cost per quality-adjusted life-year gained.
Results:
Between 23 March 2015 and 27 June 2019, 1748 participants [mean age 62 years (standard deviation 13 years), 64% male, mean Global Registry Of Acute Coronary Events score 115 (standard deviation 35)] were randomised to receive early computed tomography coronary angiography (n = 877) or standard care alone (n = 871). The primary end point occurred in 51 (5.8%) participants randomised to receive computed tomography coronary angiography and 53 (6.1%) participants randomised to receive standard care (adjusted hazard ratio 0.91, 95% confidence interval 0.62 to 1.35; p = 0.65). Computed tomography coronary angiography was associated with a reduced use of invasive coronary angiography (adjusted hazard ratio 0.81, 95% confidence interval 0.72 to 0.92; p = 0.001) but no change in coronary revascularisation (adjusted hazard ratio 1.03, 95% confidence interval 0.87 to 1.21; p = 0.76), acute coronary syndrome therapies (adjusted odds ratio 1.06, 95% confidence interval 0.85 to 1.32; p = 0.63) or preventative therapies on discharge (adjusted odds ratio 1.07, 95% confidence interval 0.87 to 1.32; p = 0.52). Early computed tomography coronary angiography was associated with longer hospitalisations (median increase 0.21 days, 95% confidence interval 0.05 to 0.40 days) and higher mean total health-care costs over 1 year (£561 more per patient) than standard care.
Limitations:
The principal limitation of the trial was the slower than anticipated recruitment, leading to a revised sample size, and the requirement to compromise and accept a larger relative effect size estimate for the trial intervention.
Future Work:
The potential role of computed tomography coronary angiography in selected patients with a low probability of obstructive coronary artery disease (intermediate or mildly elevated level of troponin) or who have limited access to invasive cardiac catheterisation facilities needs further prospective evaluation.
Conclusions:
In patients with suspected or provisionally diagnosed acute coronary syndrome, computed tomography coronary angiography did not alter overall coronary therapeutic interventions or 1-year clinical outcomes, but it did increase the length of hospital stay and health-care costs. These findings do not support the routine use of early computed tomography coronary angiography in intermediate-risk patients with acute chest pain.
Trial Registration:
This trial is registered as ISRCTN19102565 and Clinical Trials NCT02284191.
Funding:
This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 37. See the NIHR Journals Library website for further project information.
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