Early CT Coronary Angiography May Not Improve Outcomes in Suspected ACS

The use of early computed tomography (CT) coronary angiography showed no effect on treatment, prevention, or one-year outcomes for patients with acute chest pain and suspected acute coronary syndrome (ACS). The study findings were published in BMJ.

For the prospective randomized controlled trial (ClinicalTrials.gov Identifier: NCT02284191), researchers enrolled patients at 37 hospitals in the United Kingdom between 2015 and 2019. Patients suspected of having acute coronary syndrome were randomly assigned 1:1 to receive standard care alone or early CT coronary angiography. The primary composite outcome was 1-year time to first event of all-cause mortality or non-fatal type 1 or 4b myocardial infarction. Secondary endpoints included cause of death due to coronary heart disease or cardiovascular death as well as subsequent myocardial infarction.

Patients in the intervention and control cohorts had a mean age of 61.9±12.2 and 61.2±13.0 years; 64% and 63% were men; 34% and 34% had previous coronary heart disease; and 63% and 59% had an abnormal electrocardiogram, respectively.

A total of 87.5% of the intervention cohort underwent early CT coronary angiography at a median time after randomization of 4.2 (interquartile range [IQR], 1.6-21.6) hours. The angiography identified obstructive disease among 47%, non-obstructive disease among 29%, and normal coronary arteries among 23%. The CT scan was associated with 4 adverse events.

The primary composite outcome occurred among 5.8% of the intervention and 6.1% of the control cohorts (adjusted hazard ratio [aHR], 0.91; 95% CI, 0.62-1.35; P =.65).

Recipients of the early CT coronary angiography reported increased satisfaction with care (adjusted odds ratio [aOR], 1.25; 95% CI, 1.02-1.53; P =.03), were less likely to undergo invasive coronary angiography (aHR, 0.81; 95% CI, 0.72-0.92; P =.001), or non-invasive testing for coronary artery disease and myocardial ischemia (aHR, 0.66; 95% CI, 0.54-0.81; P <.001).

Early CT coronary angiography increased length of stay in the hospital (median 2.2 vs 2.0 days; P =.009).

This study was limited by power, as recruitment rates were lower than anticipated.

The study authors concluded that there was little evidence for benefit of early CT coronary angiography among patients with acute chest pain and suspected acute coronary syndrome. Although rates of some cardiac investigations were decreased, the early intervention increased healthcare utilization without decreasing risk for mortality and myocardial infarction.

“Early CT coronary angiography in intermediate risk patients presenting to the emergency department with suspected acute coronary syndrome or those with a

provisional diagnosis of acute coronary syndrome, had no effect on the overall treatment and prevention of the disease or one-year outcomes, and was associated

with an increase in the length of hospital stay,” the researchers noted. “These findings do not support the routine use of early CT coronary angiography in intermediate risk patients presenting to the emergency department with acute chest pain.”

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.

Reference

Gray AJ, Roobottom C, Smith JE, et al. Early computed tomography coronary angiography in patients with suspected acute coronary syndrome: randomised controlled trial. BMJ. 2021;374:n2106. doi:10.1136/bmj.n2106