Coronary CT angiography and 5-year risk of myocardial infarction

, David E. Newby (Lead / Corresponding author), Philip D. Adamson, Colin Berry, Nicholas A. Boon, Marc R. Dweck, Marcus Flather, John Forbes, Amanda Hunter, Stephanie Lewis, Scott MacLean, Nicholas L. Mills, John Norrie, Giles Roditi, Anoop S. V. Shah, Adam D. Timmis, Edwin J. R. Van Beek, Michelle C. Williams

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    Abstract

    Background: Although coronary computed tomographic angiography (CTA) improves diagnostic certainty in the assessment of patients with stable chest pain, its effect on 5-year clinical outcomes is unknown.

    Methods: In an open-label, multicenter, parallel-group trial, we randomly assigned 4146 patients with stable chest pain who had been referred to a cardiology clinic for evaluation to standard care plus CTA (2073 patients) or to standard care alone (2073 patients). Investigations, treatments, and clinical outcomes were assessed over 3 to 7 years of follow-up. The primary end point was death from coronary heart disease or nonfatal myocardial infarction at 5 years.

    Results: The median duration of follow-up was 4.8 years, which yielded 20,254 patientyears of follow-up. The 5-year rate of the primary end point was lower in the CTA group than in the standard-care group (2.3% [48 patients] vs. 3.9% [81 patients]; hazard ratio, 0.59; 95% confidence interval [CI], 0.41 to 0.84; P = 0.004). Although the rates of invasive coronary angiography and coronary revascularization were higher in the CTA group than in the standard-care group in the first few months of follow-up, overall rates were similar at 5 years: invasive coronary angiography was performed in 491 patients in the CTA group and in 502 patients in the standard- care group (hazard ratio, 1.00; 95% CI, 0.88 to 1.13), and coronary revascularization was performed in 279 patients in the CTA group and in 267 in the standard-care group (hazard ratio, 1.07; 95% CI, 0.91 to 1.27). However, more preventive therapies were initiated in patients in the CTA group (odds ratio, 1.40; 95% CI, 1.19 to 1.65), as were more antianginal therapies (odds ratio, 1.27; 95% CI, 1.05 to 1.54). There were no significant between-group differences in the rates of cardiovascular or noncardiovascular deaths or deaths from any cause.

    Conclusions: In this trial, the use of CTA in addition to standard care in patients with stable chest pain resulted in a significantly lower rate of death from coronary heart disease or nonfatal myocardial infarction at 5 years than standard care alone, without resulting in a significantly higher rate of coronary angiography or coronary revascularization.

    Original languageEnglish
    Pages (from-to)924-933
    Number of pages10
    JournalNew England Journal of Medicine
    Volume379
    Issue number10
    Early online date25 Aug 2018
    DOIs
    Publication statusPublished - 6 Sept 2018

    ASJC Scopus subject areas

    • General Medicine

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