Early computed tomography coronary angiography in patients with suspected acute coronary syndrome: randomised controlled trial

Abstract

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 .

Society for Cardiovascular Magnetic Resonance perspective on the 2021 AHA/ACC Chest Pain Guidelines

“…Studies evaluating FFR-CT have shown inferior incremental diagnostic and prognostic value in comparison to functional testing [ 7 , 9 ]. Additionally, the recent FORECAST (Fractional Flow Reserve Derived From Computed Tomography Coronary Angiography in the Assessment and Management of Stable Chest Pain) trial of over 1400 patients, while referral to invasive angiography was lower, the use of FFR-CT did not demonstrate any benefits in terms of healthcare costs, cardiovascular outcomes, or quality of life compared to CT-alone [ 10 ]. Similarly, the recent RAPID-CT (Rapid Assessment of Potential Ischaemic Heart Disease with CTCA) trial [ 11 ] included 1748 patients with intermediate risk with suspected or a provisional diagnosis of acute coronary syndrome randomised to Early CCTA and standard of care compared with standard of care only.…”

The Diagnostic Performance of Coronary Computed Tomographic Angiography Compared With Invasive Coronary Angiography in Symptomatic Patients: Long–term Prognostic Implications

“…CCTA clearly provides high accuracy for detecting obstructive CAD, and the high NPV determines CCTA as an effective non-invasive imaging procedure to exclude significant CAD in all risk groups, including stable symptomatic patients and those with acute coronary syndrome (17)(18)(19)(20). A previous study showed that up to 80% of ICAs can be avoided for patients with a low prevalence of CAD, since CCTA can effectively determine the need for ICA (21)(22)(23).…”

Role of Multimodality Imaging in the Assessment of Myocardial Infarction With Nonobstructive Coronary Arteries: Beyond Conventional Coronary Angiography

“…The recent VERDICT (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography in Patients with Acute Coronary Syndromes) trial showed that although CCTA may effectively rule out obstructive disease in non‐ST elevation acute coronary syndrome, with a negative predictive value of 91% and sensitivity of 97%, the RAPID‐CTCA (Rapid Assessment of Potential Ischaemic Heart Disease with CTCA [CT Coronary Angiography]) trial found that early use of CCTA did not reduce death or subsequent MI in patients presenting with suspected acute coronary syndrome. 54 , 55 …”