Early CT angiography for suspected acute coronary syndrome reduces further ischemic testing; no effect on long-term clinical outcomes

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.

Synopsis

These investigators recruited adults who presented to the emergency department with suspected acute coronary syndrome (ACS) and a history of coronary artery disease, elevated troponin levels, or an abnormal electrocardiogram. Using concealed allocation, patients were randomized to receive either early computed tomography (CT) angiography with standard of care (n = 877) or standard of care alone (n = 871). Baseline characteristics were similar in the 2 groups. Three-fourths of the total cohort were at low risk or intermediate risk based on the global registry of acute coronary events (GRACE) score. Overall, no significant difference was detected in the primary composite outcome of all-cause death or nonfatal myocardial infarction at one year in the 2 study groups (5.8% in the CT group vs 6.1% in the standard group; adjusted hazard ratio [aHR] 0.91; 95% CI 0.62 - 1.35; P = .65). Results were the same in a subgroup analysis stratified by risk scores. Over 12 months, fewer patients in the CT group had invasive coronary angiography (54.0% vs 60.8%; aHR 0.85; 0.72 - 0.92; P = .001), but a similar number underwent coronary revascularization (34.2% vs 33.1%; aHR 1.03; 0.87 - 1.21; P = .76). In a post-hoc analysis, noninvasive testing for myocardial ischemia was also lower in the CT group (19.4% vs 26.2%; aHR 0.66; 0.54 - 0.81; P < .001), but the number of other cardiac tests such as echocardiography and rhythm monitoring in each group was similar. Further, there were no significant differences in the 2 groups for drug treatment of ACS in the hospital or preventive treatment on discharge. Patients in the CT group had a longer median length of hospital stay (2.2 days vs 2.0 days; P = .009).