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Effect of Body Mass Index on Effectiveness of CT versus Invasive Coronary Angiography in Stable Chest Pain: The
Robert Sykes1, Damien Collison1, Bela Merkely1
1School of Cardiovascular and Metabolic Health, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom (R.S., D.C., C.B., C.D.); Golden Jubilee National Hospital, Clydebank, United Kingdom (D.C., C.B.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M., P.M.H., T. Bárány, B.S., M.V.N.); Departments of Cardiology (K.F.K., A.D.K.) and Radiology (K.F.K., A.D.K.), Copenhagen University Hospital-Rigshospitalet & Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Cardiology, Southeastern Health and Social Care Trust, Belfast, United Kingdom (P.D., C.O., S. Kelly, S.R.); Department of Cardiology, Hospital Universitario Vall d'Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain (J.R.P., F.X.V., B.G.d.B.); Centro de Investigación Biomédica en Red, Madrid, Spain (J.R.P., F.X.V., B.G.d.B.); Department of Cardiology, Paul Stradins Clinical University Hospital, Riga, Latvia (A.E.); University of Latvia, Riga, Latvia (A.E.); Department of Cardiology, Motol University Hospital, Prague, Czech Republic (J.V., M.H.); Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania (G.Š.); Department of Cardiology, Hospital of Lithuanian University of Health Sciences, Kaunas, Lithuania (G.Š.); Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia (N.Č.A., F.A.); Department of Cardiology, Institute for Cardiovascular Diseases of Vojvodina, Novi Sad, Serbia (N.Č.A., F.A.); Department of Radiology, University of Leipzig Heart Centre, Leipzig, Germany (M.G.); Department of Radiology, St. Vincent's University Hospital, Dublin, Ireland (J.D.D.); School of Medicine, University College Dublin, Dublin, Ireland (J.D.D.); Department of Cardiology, Basurto Hospital, Bilbao, Spain (I.D., A.R.); Departments of Cardiology (G.D.) and Radiology (E.T.), Aintree University Hospital, Liverpool, United Kingdom; Edge Hill University, Ormskirk, United Kingdom (G.D.); Department of Radiology, Charité-Universitätsmedizin Berlin Campus Mitte, Charitéplatz 1, Freie Universität Berlin and Humboldt-Universität zu 10117 Berlin, Germany (E.Z., S.F., M. Mohamed, M.R., V.W., M.E., M.B., M.D.); National Institute of Cardiology, Warsaw, Poland (C. Kępka, M.K.); Department of Cardiology, Internal Medicine Clinic, Clinical Hospital Center Zemun, Belgrade, Serbia (R.V., A.Z.); Faculty of Medicine, University of Belgrade, Belgrade, Serbia (R.V.); Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Rome, Italy (M. Francone); Department of Biomedical Sciences, Humanitas University, Milan, Italy (M. Francone); Department of Cardiology, Provincial Specialist Hospital in Wroclaw, Wroclaw, Poland (M.I.S.); Department of Internal Medicine III, Department of Cardiology, Innsbruck Medical University, Innsbruck, Austria (F.P.); Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland (J.K.); Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia-Espinho, Vila Nova de Gaia, Portugal (R.F., V.G.R.); Department of Cardiology, Alb Fils Kliniken, Göppingen, Germany (S.S., T.D.); Department of Radiology, University of Cagliari, Cagliari, Italy (L.S.); Department of Cardiology, Royal Liverpool University Hospital, Liverpool, United Kingdom (B.R., M. Fisher); Institute for Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom (B.R., M. Fisher); Institute of Public Health, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany (N.R.); ECRIN-ERIC (European Clinical Research Infrastructure Network-European Research Infrastructure Consortium), Paris, France (C. Kubiak); Department of Public Health, Section for Health Services Research, University of Copenhagen, Copenhagen, Denmark (K.S.H.); Bavarian Cancer Registry, Bavarian Health and Food Safety Authority, Munich, Germany (J.M.N.); Department of Radiology, Medical Imaging Center, Semmelweis University, Budapest, Hungary (P.M.H.); Center of Advanced Research in Multimodality Cardiac Imaging, CardioMed Medical Center, Targu Mures, Romania (I.B., I.R.); Department of Radiology, Paul Stradins Clinical University Hospital, Riga, Latvia (L.Z.); Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania (A.J.); Department of Radiology, Kaunas Clinics, Kaunas, Lithuania (A.J.); Department of Cardiology, University of Leipzig Heart Centre, Leipzig, Germany (M.W.); Department of Cardiology, St. Vincent's University Hospital, University College Dublin, Dublin, Ireland (S. Keane); Department of Radiology, Basurto Hospital, Bilbao, Spain (I.L.); Department of Cardiology and Angiology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany (M.L., H.D.); Department of Clinical Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy (M. Mancone); Department of Radiology, Provincial Specialist Hospital in Wroclaw, Wroclaw, Poland (D.K.); Department of Radiology, Innsbruck Medical University, Innsbruck, Austria (G.F.); Heart Center, Turku University Hospital and University of Turku, Turku, Finland (M. Pietilä); Administrative Centre, Health Care District of Southwestern Finland, Turku, Finland (M. Pietilä); Department of Radiology, University of Cagliari, Cagliari, Italy (M. Porcu); Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom (M. Fisher); Department of Cardiology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark (C.S.); Department of Cardiology, George Emil Palade University of Medicine, Pharmacy, Science and Technology, Tirgu Mures, Romania (R.A.); Section of Cardiology, Department of Medicine, Copenhagen University Hospital of Glostrup, Glostrup, Denmark (J.A.); Department of Radiology, Hospital Universitario Vall d'Hebron, Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain (H.C.C.); Department of Cardiology, Nordsjaellands Hospital, Hillerod, Denmark (B.J.); Department of Internal Medicine, Clinic of Cardiology, George Emil Palade University of Medicine, Pharmacy, Science and Technology, Targu Mures, Romania (R.H., T. Benedek); DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany; Berlin Institute of Health, Berlin, Germany (H.D., M.D.); Berlin University Alliance, Berlin, Germany (M.D.); Department of Clinical Epidemiology and Applied Biostatistics, Universitätsklinikum Tübingen, Tübingen, Germany (L.M.S.H., P.M.); Institute of Biometry and Clinical Epidemiology, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany (K.N.); Oregon Health & Science University, Portland, Ore (M. Ferencik); County Clinical Emergency Hospital Targu Mures, Targu Mures, Romania (T. Benedek); Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany (M.D.); and Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany (M.D.).
Abstract:
Background Recent trials support the role of cardiac CT in the evaluation of symptomatic patients suspected of having coronary artery disease (CAD); however, body mass index (BMI) has been reported to negatively impact CT image quality. Purpose To compare initial use of CT versus invasive coronary angiography (ICA) on clinical outcomes in patients with stable chest pain stratified by BMI category. Materials and Methods This prospective study represents a prespecified BMI subgroup analysis of the multicenter Diagnostic Imaging Strategies for Patients with Stable Chest Pain and Intermediate Risk of Coronary Artery Disease (DISCHARGE) trial conducted between October 2015 and April 2019. Adult patients with stable chest pain and a CAD pretest probability of 10%-60% were randomly assigned to undergo initial CT or ICA. The primary end point was major adverse cardiovascular events (MACE), including cardiovascular death, nonfatal myocardial infarction, or stroke. The secondary end point was an expanded MACE composite, including transient ischemic attack, and major procedure-related complications. Competing risk analyses were performed using the Fine and Gray subdistribution Cox proportional hazard model to assess the impact of the relationship between BMI and initial management with CT or ICA on the study outcomes, whereas noncardiovascular death and unknown causes of death were considered competing risk events. Results Among the 3457 participants included, 831 (24.0%), 1358 (39.3%), and 1268 (36.7%) had a BMI of less than 25, between 25 and 30, and greater than 30 kg/m2, respectively. No interaction was found between CT or ICA and BMI for MACE (P = .29), the expanded MACE composite (P = .38), or major procedure-related complications (P = .49). Across all BMI subgroups, expanded MACE composite events (CT, 10 of 409 [2.4%] to 23 of 697 [3.3%]; ICA, 26 of 661 [3.9%] to 21 of 422 [5.1%]) and major procedure-related complications during initial management (CT, one of 638 [0.2%] to five of 697 [0.7%]; ICA, nine of 630 [1.4%] to 12 of 422 [2.9%]) were less frequent in the CT versus ICA group. Participants with a BMI exceeding 30 kg/m² exhibited a higher nondiagnostic CT rate (7.1%, P = .044) compared to participants with lower BMI. Conclusion There was no evidence of a difference in outcomes between CT and ICA across the three BMI subgroups. Clinical trial registration no. NCT02400229 © RSNA, 2024 Supplemental material is available for this article.
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