#VisualAbstract: CT associated with lower risk of complications than invasive coronary angiography

1. In patients with stable chest pain and an intermediate pre-test probability of coronary artery disease (CAD), there was no difference in the risk of major adverse cardiovascular events between those undergoing computed tomography (CT) and invasive coronary angiography (ICA).

2. CT scan was associated with fewer procedural complications than ICA.

Evidence rating level: 1 (Excellent)

Summary of the study: In patients with stable chest pain and an intermediate pre-test probability of obstructive coronary artery disease, ICA is the gold standard for diagnosis and allows for revascularization therapy if obstruction occurs. Nevertheless, elective ICA in such a patient population is associated with rare but major procedure-related complications, while potentially detecting obstructions in only 50% of patients undergoing this procedure. CT scanning is an accurate, noninvasive alternative to ICA that can rule out obstructive coronary artery disease and identify candidates for revascularization therapy with lower risks of ICA-related complications. The current study compared CT to ICA as an initial diagnostic step for patients with stable chest pain who were referred for testing. Over 3.5 years, patients undergoing CT had a similar risk of developing major adverse cardiovascular events (MACE) and angina, compared to the ICA group. However, procedural complications occurred less frequently in patients in the CT group. Taken together, these findings add to the body of evidence supporting the use of CT as a first diagnostic step over AFI, to guide the management of patients with stable chest pain.

Click here to read the study in the NEJM

Relevant reading: CT scan evaluation in patients with atypical angina or chest pain referred clinically for invasive coronary angiography: random controlled trial

In depth [randomized controlled trial]: The current study was a multicenter, pragmatic, randomized trial comparing CT to ICA as an initial diagnostic test to guide the management of patients with stable chest pain and an intermediate pre-test probability of coronary artery disease. who had been referred for the CIA. 3561 patients (56.2% were women) were recruited and analyzed at 26 European sites. Eligible patients were at least 30 years old and clinically indicated for ICA to assess their chest pain. The intermediate probability of the pretest was defined between 10 and 60% on the basis of a validated calculator. Patients were excluded if they were receiving hemodialysis, lacked sinus rhythm, or were pregnant. Patients were randomized 1:1 to undergo CT or ICA. Patients were discharged if obstructive coronary artery disease was ruled out, while positive coronary artery disease findings prompted guideline-recommended treatment, including medical and revascularization therapies. The primary outcome was the occurrence of MACE, a composite measure of cardiovascular death, nonfatal myocardial infarction, and stroke. Secondary outcomes included components of MACE, angina, and major procedural complications. Outcome assessors were not informed of group assignments. Median follow-up was 3.5 years and outcomes were assessed using a modified intention-to-treat analysis. The occurrence of a composite MACE was 38 of 1808 patients (2.1%) in the CT group and 52 of 1753 patients (3.0%) in the ICA group (relative risk [HR], 0.7; 95% confidence interval [CI], 0.46 to 1.07; p=0.10). Levels of each MACE component were comparable between the two groups. Major procedure-related complications (from diagnostic ICA and indicated revascularization procedures) occurred in 9 patients (0.5%) in the CT group and 33 patients (1.9%) in the ICA group (HR, 0 .26; 95% CI, 0.13 to 0.55). The expanded composite outcome of MACE and procedural complications occurred in 50 patients (2.8%) in the CT group and in 80 patients (4.6%) in the ICA group (HR, 0.60; 95% CI %, 0.42 to 0.85). The incidence of angina was 8.8% in the CT group and 7.5% in the ICA group (odds ratio, 1.17; 95% CI, 0.92 to 1.48). Limitations of the study included unblinded group assignments and potential bias favoring the ICA group. Nonetheless, its pragmatic design, high protocol compliance, and comprehensive follow-up bolstered its results. Overall, the study showed that, compared to ICA, using CT as an initial test was associated with similar MACE results, but with a lower risk of procedure-related complications for patients. suffering from stable chest pain.

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