TY - JOUR
T1 - Initial Imaging-Guided Strategy Versus Routine Care in Patients With Non-ST-Segment Elevation Myocardial Infarction
AU - Smulders, Martijn W.
AU - Kietselaer, Bas L. J. H.
AU - Wildberger, Joachim E.
AU - Dagnelie, Pieter C.
AU - Brunner-La Rocca, Hans-Peter
AU - Mingels, Alma M. A.
AU - van Cauteren, Yvonne J. M.
AU - Theunissen, Ralph A. L. J.
AU - Post, Mark J.
AU - Schalla, Simon
AU - van Kuijk, Sander M. J.
AU - Das, Marco
AU - Kim, Raymond J.
AU - Crijns, Harry J. G. M.
AU - Bekkers, Sebastiaan C. A. M.
N1 - Funding Information:
The authors acknowledge the Independent Interim Analysis Committee (P.J. Nelemans, Epidemiology, Maastricht University Medical Center; K. Nieman, Cardiology, Erasmus UMC, Rotterdam, and Department of Cardiovascular Medicine and Radiology, Stanford UMC, Stanford, CA; R. Nijveldt, Cardiology, Radboud UMC, Nijmegen), the Independent Final Diagnosis and Clinical Events Committee (J.C.A. Hoorntje, Cardiology, Zuyderland MC, Heerlen/Maastricht University Medical Center; R. Nijveldt, Cardiology, Radboud UMC, Nijmegen; M. van der Vlugt, Cardiology, Radboud UMC, Nijmegen), the Independent Contrast Induced Nephropathy Event Committee (R.J.M.W. Rennenberg, Internal Medicine, Maastricht University Medical Center; V.V.A. van Ommen, Cardiology, Maastricht University Medical Center; E.C. Nijssen, Radiology and Nuclear Medicine, Maastricht University Medical Center), the independent radiation protection expert (C.R.L.P.N. Jeukens, Radiology and Nuclear Medicine, Maastricht University Medical Center), and J. Heijman, Cardiology, Maastricht University Medical Center, for language editing.
Publisher Copyright:
© 2019 American College of Cardiology Foundation
PY - 2019/11/19
Y1 - 2019/11/19
N2 - BACKGROUND Patients with non-ST-segment elevation myocardial infarction and elevated high-sensitivity cardiac troponin levels often routinely undergo invasive coronary angiography (ICA), but many do not have obstructive coronary artery disease.OBJECTIVES This study investigated whether cardiovascular magnetic resonance imaging (CMR) or computed tomographic angiography (CTA) may serve as a safe gatekeeper for ICA.METHODS This randomized controlled trial (NCT01559467) in 207 patients (age 64 years; 62% male patients) with acute chest pain, elevated high-sensitivity cardiac troponin T levels (>14 ng/l), and inconclusive electrocardiogram compared a CMR- or CTA-first strategy with a control strategy of routine clinical care. Follow-up ICA was recommended when initial CMR or CTA suggested myocardial ischemia, infarction, or obstructive coronary artery disease ($70% stenosis). Primary efficacy and secondary safety endpoints were referral to ICA during hospitalization and 1-year outcomes (major adverse cardiac events and complications), respectively.RESULTS The CMR- and CTA-first strategies reduced ICA compared with routine clinical care (87% [p = 0.001], 66% [p <0.001], and 100%, respectively), with similar outcome (hazard ratio: CMR vs. routine, 0.78 [95% confidence interval: 0.37 to 1.61]; CTA vs. routine, 0.66 [95% confidence interval: 0.31 to 1.42]; and CMR vs. CTA, 1.19 [95% confidence interval: 0.53 to 2.66]). Obstructive coronary artery disease after ICA was found in 61% of patients in the routine clinical care arm, in 69% in the CMR-first arm (p = 0.308 vs. routine), and in 85% in the CTA-first arm (p = 0.006 vs. routine). In the non-CMR and non-CTA arms, follow-up CMR and CTA were performed in 67% and 13% of patients and led to a new diagnosis in 33% and 3%, respectively (p <0.001).CONCLUSIONS A novel strategy of implementing CMR or CTA first in the diagnostic process in non-ST-segment elevation myocardial infarction is a safe gatekeeper for ICA. (J Am Coll Cardiol 2019;74:2466-77) (c) 2019 by the American College of Cardiology Foundation.
AB - BACKGROUND Patients with non-ST-segment elevation myocardial infarction and elevated high-sensitivity cardiac troponin levels often routinely undergo invasive coronary angiography (ICA), but many do not have obstructive coronary artery disease.OBJECTIVES This study investigated whether cardiovascular magnetic resonance imaging (CMR) or computed tomographic angiography (CTA) may serve as a safe gatekeeper for ICA.METHODS This randomized controlled trial (NCT01559467) in 207 patients (age 64 years; 62% male patients) with acute chest pain, elevated high-sensitivity cardiac troponin T levels (>14 ng/l), and inconclusive electrocardiogram compared a CMR- or CTA-first strategy with a control strategy of routine clinical care. Follow-up ICA was recommended when initial CMR or CTA suggested myocardial ischemia, infarction, or obstructive coronary artery disease ($70% stenosis). Primary efficacy and secondary safety endpoints were referral to ICA during hospitalization and 1-year outcomes (major adverse cardiac events and complications), respectively.RESULTS The CMR- and CTA-first strategies reduced ICA compared with routine clinical care (87% [p = 0.001], 66% [p <0.001], and 100%, respectively), with similar outcome (hazard ratio: CMR vs. routine, 0.78 [95% confidence interval: 0.37 to 1.61]; CTA vs. routine, 0.66 [95% confidence interval: 0.31 to 1.42]; and CMR vs. CTA, 1.19 [95% confidence interval: 0.53 to 2.66]). Obstructive coronary artery disease after ICA was found in 61% of patients in the routine clinical care arm, in 69% in the CMR-first arm (p = 0.308 vs. routine), and in 85% in the CTA-first arm (p = 0.006 vs. routine). In the non-CMR and non-CTA arms, follow-up CMR and CTA were performed in 67% and 13% of patients and led to a new diagnosis in 33% and 3%, respectively (p <0.001).CONCLUSIONS A novel strategy of implementing CMR or CTA first in the diagnostic process in non-ST-segment elevation myocardial infarction is a safe gatekeeper for ICA. (J Am Coll Cardiol 2019;74:2466-77) (c) 2019 by the American College of Cardiology Foundation.
KW - cardiovascular magnetic resonance
KW - computed tomographic angiography
KW - high-sensitive cardiac troponin
KW - invasive coronary angiography
KW - non-ST-segment elevation myocardial infarction
KW - CARDIOVASCULAR MAGNETIC-RESONANCE
KW - ACUTE CORONARY SYNDROME
KW - COMPUTED-TOMOGRAPHY ANGIOGRAPHY
KW - ACUTE CHEST-PAIN
KW - INVASIVE STRATEGY
KW - EMERGENCY-DEPARTMENT
KW - UNSTABLE ANGINA
KW - CT ANGIOGRAPHY
KW - GUIDELINES
KW - INTERVENTION
U2 - 10.1016/j.jacc.2019.09.027
DO - 10.1016/j.jacc.2019.09.027
M3 - Article
C2 - 31727284
SN - 0735-1097
VL - 74
SP - 2466
EP - 2477
JO - Journal of the American College of Cardiology
JF - Journal of the American College of Cardiology
IS - 20
ER -