Trial does not support early coronary CTA among higher-risk patients with suspected ACS
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An analysis of 1-year outcomes did not support the use of early coronary CT angiography among intermediate and high-risk patients with suspected ACS, according to the results of the RAPID-CTCA trial.
Early coronary CT angiography (CCTA) plus standard care did not reduce risk for all-cause death or subsequent MI among these patients and increased the length of hospital stay and health care costs compared with standard care alone, according to data presented at the virtual American Heart Association Scientific Sessions.
“Endpoint event rates across both arms were around 6% at 1 year,” Alasdair Gray, MBChB, MD, FRCS, FCEM, clinical director and professor of emergency medicine at Edinburgh Emergency Medicine, Scotland, said during a presentation. “However, there was no evidence of difference between CT and standard care alone for the primary endpoint. Additionally, there was no evidence of benefits or otherwise in key secondary outcomes, including all cause death, coronary heart disease death, cardiovascular death or nonfatal MI, either together or in isolation.
“We were thoughtful about the relative heterogeneity of the inclusion criteria in this pragmatic trial, so we did a number of prespecified subgroup analyses to determine more specific risk groups from intermediate to higher risk. There is no clear difference between CT and standard care,” he said.
For the prospective randomized trial, researchers assigned 1,748 high-risk patients (mean age, 62 years; 64% men) at 37 centers with a suspected or provisional diagnosis of ACS and history of CHD, troponin levels in the 99th percentile or an abnormal 12-lead ECG finding to undergo early CCTA plus standard care or standard care alone. The primary endpoint was all-cause death or MI at 1 year.
CCTA was performed a median of 4.2 hours from randomization and diagnostic quality was achieved in more than 90% of the cohort.
For the primary endpoint of all-cause death or subsequent MI at 1 year, researchers observed no difference between the CCTA plus standard care and standard care only groups (adjusted HR = 0.91; 95% CI, 0.62-1.35; P = .65).
In none of the prespecified subgroup analyses (age, sex, prior CHD, elevated troponin, abnormal ECG, GRACE score and presence or absence of onsite invasive coronary angiography facilities) did the primary endpoint reach statistical significance.
The CCTA group was less likely to undergo invasive coronary angiography compared with the control group (aHR = 0.81; 95% CI, 0.72-0.92; P = .001), but there were no differences between the groups in revascularization (aHR = 1.03; 95% CI, 0.87-1.21; P = .76), Gray said.
In addition, researchers observed no difference in overall ACS treatment (aOR = 1.06; 95% 95% CI, 0.85-1.32; P = .63) or preventative therapies (aOR = 1.07 (95% CI, 0.87-1.31; P = .55), among patients who received CCTA compared with standard care alone.
“Unlike previous trials of stable and low-risk acute chest pain, the use of CT in our population that was intermediate to high-risk did not increase coronary artery disease diagnosis; it reduced invasive angiography rather than increasing it; and there was no difference between the trial allocations for important treatment and clinical outcomes,” Gray said.
Compared with standard care alone, intermediate or high-risk patients who received CCTA for suspected ACS experienced:
- increased diagnostic certainty (mean of 7.1 to 8.5 with 10 being the most certain);
- greater satisfaction (83.3% vs. 79.7%);
- longer hospital stay (2.2 days vs. 2 days; difference, 0.21 days; 95% CI, 0.05-0.4);
- higher mean health care costs ($9,494 vs. $8,776); and
- no difference in subsequent hospital attendance or admissions with chest pain (aHR = 1.06; 95% CI, 0.83-1-34; P = .66).
“Early coronary CT angiography... had no impact on overall treatment or prevention of acute coronary syndromes or important 1-year clinical outcomes and was associated with a modest increase in length of hospital stay and health care costs,” Gray said during the presentation. “These findings do not support the routine use of early coronary CT angiography in intermediate or high-risk patients with acute chest pain.”
Following the presentation, discussant Judith S. Hochman, MD, senior associate dean for clinical sciences, co-director of the Clinical and Translational Science Institute, Harold Snyder Family Professor, associate director of cardiology and director of the Cardiovascular Clinical Research Center at the NYU School of Medicine, said, “I agree with the investigators that these findings do not support the routine use of early CCTA in intermediate or high-risk patients with suspected acute coronary syndrome in this era of using rapid troponin tests to make the diagnosis. There was equal use of revascularization, which suggests the clinician selected patients appropriately in both groups.
“We know that the highest GRACE score patients generally benefit from revascularization, but I wanted to point out two other interesting findings. Under what circumstances might CCTA lead to improved clinical outcomes,” Hochman said. “When you visualize atherosclerotic disease, it leads to implementation of therapies to improve clinical outcomes and SCOT-HEART was a landmark trial that actually showed that that was the case. Patients visualized with nonobstructive disease had more statin and aspirin prescribed, which led to a lower death and MI event rate. Last year's AHA presidential advisory showed that we have an opportunity to reduce the odds of cardiovascular death by 80% if we can get our patients to achieve risk factor modification.”
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Gray A, et al. LBS.07: Randomized trials – Brain, kidney and heart. Presented at: American Heart Association Scientific Sessions; Nov. 13-17, 2020 (virtual meeting).
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