Early computed tomography coronary angiography in adults presenting with suspected acute coronary syndrome: the RAPID-CTCA RCT

Abstract

Background Acute coronary syndrome is a common medical emergency. The optimal strategy to investigate patients who are at intermediate risk of acute coronary syndrome has not been fully determined. Objective To investigate the role of early computed tomography coronary angiography in the investigation and treatment of adults presenting with suspected acute coronary syndrome. Design A prospective, multicentre, open, parallel-group randomised controlled trial with blinded end-point adjudication. Setting Thirty-seven hospitals in the UK. Participants Adults (aged ≥ 18 years) presenting to the emergency department, acute medicine services or cardiology department with suspected or provisionally diagnosed acute coronary syndrome and at least one of the following: (1) a prior history of coronary artery disease, (2) a cardiac troponin level > 99th centile and (3) an abnormal 12-lead electrocardiogram. Interventions Early computed tomography coronary angiography in addition to standard care was compared with standard care alone. Participants were followed up for 1 year. Main outcome measure One-year all-cause death or subsequent type 1 (spontaneous) or type 4b (stent thrombosis) myocardial infarction, measured as the time to such event adjudicated by two cardiologists blinded to the computerised tomography coronary angiography (CTCA) arm. Cost-effectiveness was estimated as the lifetime incremental cost per quality-adjusted life-year gained. Results Between 23 March 2015 and 27 June 2019, 1748 participants [mean age 62 years (standard deviation 13 years), 64% male, mean Global Registry Of Acute Coronary Events score 115 (standard deviation 35)] were randomised to receive early computed tomography coronary angiography (n = 877) or standard care alone (n = 871). The primary end point occurred in 51 (5.8%) participants randomised to receive computed tomography coronary angiography and 53 (6.1%) participants randomised to receive standard care (adjusted hazard ratio 0.91, 95% confidence interval 0.62 to 1.35; p = 0.65). Computed tomography coronary angiography was associated with a reduced use of invasive coronary angiography (adjusted hazard ratio 0.81, 95% confidence interval 0.72 to 0.92; p = 0.001) but no change in coronary revascularisation (adjusted hazard ratio 1.03, 95% confidence interval 0.87 to 1.21; p = 0.76), acute coronary syndrome therapies (adjusted odds ratio 1.06, 95% confidence interval 0.85 to 1.32; p = 0.63) or preventative therapies on discharge (adjusted odds ratio 1.07, 95% confidence interval 0.87 to 1.32; p = 0.52). Early computed tomography coronary angiography was associated with longer hospitalisations (median increase 0.21 days, 95% confidence interval 0.05 to 0.40 days) and higher mean total health-care costs over 1 year (£561 more per patient) than standard care. Limitations The principal limitation of the trial was the slower than anticipated recruitment, leading to a revised sample size, and the requirement to compromise and accept a larger relative effect size estimate for the trial intervention. Future work The potential role of computed tomography coronary angiography in selected patients with a low probability of obstructive coronary artery disease (intermediate or mildly elevated level of troponin) or who have limited access to invasive cardiac catheterisation facilities needs further prospective evaluation. Conclusions In patients with suspected or provisionally diagnosed acute coronary syndrome, computed tomography coronary angiography did not alter overall coronary therapeutic interventions or 1-year clinical outcomes, but it did increase the length of hospital stay and health-care costs. These findings do not support the routine use of early computed tomography coronary angiography in intermediate-risk patients with acute chest pain. Trial registration This trial is registered as ISRCTN19102565 and Clinical Trials NCT02284191. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 37. See the NIHR Journals Library website for further project information.

Comparative Effectiveness of Coronary CT Angiography and Standard of Care for Evaluating Acute Chest Pain: A Living Systematic Review and Meta-Analysis

“…Then, 29 studies were excluded because of lack of intervention or control arm; duplicated reports of the same research; incorrect study design (eg, not randomized); lack of relevant outcome; publication reporting only the study design; or because it was a review, editorial, commentary, or abstract. Finally, 22 RCTs ( 10 – 12 , 17 – 19 , 21 – 36 ) were included in the final analysis, representing a total of 9379 participants, with 4956 participants assigned to the CCTA arms and 4423 participants assigned to the SOC arms. The follow-up length ranged from 28 days to more than 5 years among studies.…”

“…This is supported by our findings which revealed no evidence of a difference in LOS between CCTA and SOC arms in studies containing greater than or equal to 10% of high-risk participants. Of note, one of the studies in this group ( 12 ) randomized participants during their original visit at the ED, hospital, or cardiology unit but allowed CCTA to be performed either during that visit or after discharge within 72 hours of randomization. This study revealed a 10% increase in the LOS for the CCTA arm (95% CI: 0%, 21%).…”

“…Previous meta-analyses corroborate the safety of CCTA compared with the standard of care (SOC) in the evaluation of ACP ( 6 – 9 ) suggesting the potential for reductions in use of health care resources as measured by length of ED and hospital stays (LOS) and overall costs. However, recent randomized controlled trials (RCTs) failed to reproduce those results ( 10 – 12 ). Reconciliation of these conflicting data is imperative to consolidate the strategic role of CCTA for assessing ACP ( 4 ).…”

Cardiac Biomarkers in 2022 – a Vital Tool for Emergency Care

“…24 The RAPID-CTCA RCT study investigated the role of early CCTA in patients presenting to the ED for chest pain and suspected ACS, and failed to demonstrate a significant reduction of the revascularization rates, ACS therapies, or preventative therapies at discharge following early CCTA in patients with elevated cTn. 25 This underlines the superiority of cTn as a first-line diagnostic test for triage of patients with suspected ACS in the ED, elevated cTn levels being sufficient for establishing the diagnosis in the absence of other expensive techniques.…”