Early computed tomography coronary angiography (CTCA) in intermediate- or high-risk patients presenting to the emergency department with suspected or provisionally diagnosed acute coronary syndrome (ACS) did not impact overall treatment or prevention of ACS but was associated with a modest increase in length of stay and healthcare costs, according to late-breaking trial results presented Monday at the American Heart Association Scientific Sessions 2020 virtual conference.
Emergency department visits for chest pain continue to be a global health concern. Routine evaluation for ACS includes history, physical examination, electrocardiogram and serial troponin testing. Adjunct CTCA has been studied in low-risk patients but data on intermediate and high-risk patients is lacking.
Alasdair Gray, MD, of the University of Edinburgh, United Kingdom, presented the results of the prospective, randomized, open blinded endpoint parallel group clinical trial of early CTCA in the management of intermediate- and high-risk patients presenting to the emergency department with suspected or provisionally diagnosed with ACS. Patients were considered intermediate- or high-risk if they had at least one of the following: prior history of coronary artery disease, troponin elevation >99th percentile and an abnormal electrocardiogram.
In this trial, patients were randomized to CTCA or standard of care. The primary outcome of interest was all-cause mortality or a type 1 or 4b myocardial infarction at 1 year.
The study included 1,748 patients across 37 sites in the United Kingdom from 2015 through 2019, of whom 877 were randomized to CTCA and standard of care, with the remaining 871 receiving the standard of care only. The mean age of patients was 62 years, and 64% were men.
In the CTCA group, a CTCA was performed in 87% of patients (767) a median of 4.2 hours from randomization, with >90% achieving diagnostic quality. The mean effective radiation dose was 3.1 mSv, with half of patients having non-obstructive coronary artery disease.
With regard to the primary outcome of all-cause mortality or subsequent myocardial infarction, there was no statistically significant difference (adjusted hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.62, 1.35; p=0.65).
There were no significant differences in any of the individual key secondary outcomes relating to all-cause mortality, coronary heart disease, cardiovascular death or non-fatal myocardial infarction. Furthermore, there were no differences in overall ACS treatment or preventative therapies between the two groups.
Diagnostic certainty did increase in the CTCA group (7.1 to 8.5 using a scale from 1 to 10, with 10 being the most certain) and there was an increase in participant satisfaction (from 79.7% to 83.3%).
Despite this, median length of stay was the same in both groups, (2.2 vs. 2.0 days) and mean healthcare costs ($9,494 vs. $8,776) favored the standard of care group.
“These findings do not support the routine use of early coronary CT angiography in intermediate- or high-risk patients with acute chest pain,” Gray concluded.
The RAPID CTCA trial was funded by the National Institute for Health Research (NIHR) Health Technology Assessment Programme.