Initial Imaging-Guided Strategy Versus Routine Care in Patients With Non-ST-Segment Elevation Myocardial Infarction.
J Am Coll Cardiol
; 74(20): 2466-2477, 2019 11 19.
Article
in En
| MEDLINE
| ID: mdl-31727284
ABSTRACT
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.Key words
Full text:
1
Database:
MEDLINE
Main subject:
Magnetic Resonance Imaging
/
Cardiac Imaging Techniques
/
Non-ST Elevated Myocardial Infarction
/
Computed Tomography Angiography
Type of study:
Clinical_trials
/
Guideline
Limits:
Aged
/
Female
/
Humans
/
Male
/
Middle aged
Language:
En
Journal:
J Am Coll Cardiol
Year:
2019
Type:
Article
Affiliation country:
Netherlands