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Published on: August 28, 2018
Coronary calcium scoring in the evaluation of stable chest pain in general practice: a cluster-randomised trial
Moniek Y Koopman1, Thom E J Severijn2, Jorn J W Reijnders3
1Department of Radiology, UMCG, Groningen, The Netherlands.
Insights
Coronary artery calcium scoring (CACS) effectively identified patients with low likelihood of obstructive coronary artery disease (OCAD), reducing cardiology referrals. However, it did not significantly impact overall cardiovascular risk management registrations at the GP office level.
Area of Science:
- Cardiology
- Primary Care Medicine
- Diagnostic Imaging
Background:
- General practitioners (GPs) lack sufficient tools for diagnosing coronary artery disease (CAD) in chest pain patients.
- The coronary artery calcium score (CACS) offers a potential solution for assessing (non-)obstructive coronary artery disease (OCAD).
Purpose of the Study:
- To evaluate if GP access to CACS improves diagnostic efficiency for chest pain patients.
- To assess the impact of CACS on cardiovascular risk management (CVRM) in primary care.
Main Methods:
- The COroNary Calcium scoring as fiRst-linE Test to dEtect and exclude coronary artery disease (CONCRETE) study was a pragmatic, cluster-randomized trial involving 101 Dutch GP offices.
- Patients aged 40+ (men) or 45+ (women) with stable chest pain were randomized to CACS or standard of care (SOC).
- Primary outcome was the 2-year increase in CVRM registrations; secondary outcomes included referral rates and OCAD diagnosis.
Main Results:
- No significant difference in CVRM registration increase at the GP office level between CACS and SOC groups.
- The CACS arm showed a 47.1% relative reduction in cardiologist referrals compared to SOC (42.5% vs 80.3%).
- More CACS patients were enrolled in CVRM (36.3% vs 17.0%, p<0.01), and higher CACS correlated with increased referral and OCAD diagnosis probability.
Conclusions:
- CACS is an effective diagnostic tool in primary care for stable chest pain patients with a low likelihood of OCAD.
- CACS implementation reduced unnecessary cardiology referrals and improved individual preventive care.
- No demonstrable practice-level impact on CVRM registrations was observed in this trial.
Background:
General practitioners (GPs) have limited tools for chest pain patients to identify (non-)obstructive coronary artery disease (OCAD). This trial evaluates whether GP access to the coronary artery calcium score (CACS) improves diagnostic efficiency and cardiovascular risk management (CVRM).
Methods:
COroNary Calcium scoring as fiRst-linE Test to dEtect and exclude coronary artery disease in GP patients with stable chest pain (CONCRETE) is a pragmatic, non-blinded implementation study that cluster-randomised 101 Dutch GP offices into CACS or standard of care (SOC). Patients aged ≥40 (men) or ≥45 (women) years, without known CAD, with possible cardiac or non-cardiac chest pain were included. The primary outcome was the proportional 2-year increase in CVRM registrations at GP office level. Patient-level secondary outcomes included cardiologist referral rate, OCAD diagnosis and CVRM enrolment.
Results:
At GP office level, no significant difference in CVRM registration increase was seen for CACS versus SOC (46 CACS practices: +0.3%, 45 SOC practices: +0.2%, p=0.77). Per protocol analysis for patient-level outcomes included 583 patients (57.5% women, mean age 60.6±9.1 years) (CACS arm: 466; SOC arm: 117), recruited between January 2019 and October 2023. The CACS arm showed 47.1% relative reduction in cardiologist referrals compared with SOC (42.5% vs 80.3%; modelled difference 31.3% (95% CI 14.8% to 47.8%)). OCAD detection rates were not significantly different (CACS: 4.9, SOC: 7.7%, p=0.14). Patients with higher CACS had a higher probability of cardiologist referral (from 8.4% for CACS 0 to 94.2% for CACS ≥400, difference +85.7% (95% CI 79.4% to 91.9%)) and of OCAD diagnosis (0% for CACS 0 to 21.2% for CACS ≥400, OR 9.08 (95% CI 4.20 to 19.67)). Compared with SOC, more CACS patients were enrolled in CVRM (36.3% vs 17.0%, p<0.01).
Conclusions:
In this pragmatic, primary-care implementation and proof-of-concept trial, CACS was an effective diagnostic test for stable chest pain patients with (very) low likelihood of OCAD. CACS reduced unnecessary cardiology referrals and enhanced individual preventive care, without demonstrable practice-level impact on CVRM registrations.
Registration:
The CONCRETE study is registered under CCMO Register NL66821.042.18 and closed for enrolment.
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