Early CT Coronary Angiography in Patients with Suspected Acute Coronary Syndrome: Randomised Controlled Trial

Objectives: To establish whether early computed tomography (CT) coronary angiography in intermediate-risk patients presenting to the Emergency Department with acute chest pain could improve one-year clinical outcomes.
Design: Prospective randomised open blinded-endpoint parallel-group clinical trial, with 1:1 randomisation between the intervention and standard care arm.
Setting: 37 UK hospitals.
Participants: Adults with suspected or provisionally diagnosed acute coronary syndrome and one of prior coronary heart disease, elevated cardiac troponin or ischaemic electrocardiogram.
Interventions: Early CT coronary angiography and standard of care compared with standard of care alone.
Main outcome measures: The primary endpoint was one-year all-cause death or subsequent type 1 or 4b myocardial infarction.
Results: Between 23rd March 2015 and 27th June 2019, 1748 participants (mean age 62 (SD 13) years, 64% male, mean GRACE score 115 (standard deviation 35)) were randomised to early CT coronary angiography (n=877) or standard of care alone (n=871). The median time from randomisation to CT coronary angiography was 4·2 [interquartile range 1·6 to 21·6] hours. The primary endpoint occurred in 51 (5·8%) participants randomised to CT coronary angiography and 53 (6·1%) participants with standard of care alone (adjusted hazard ratio 0·91 (95% confidence interval, 0·62 to 1·35), P=0·65). Invasive coronary angiography occurred in 474 (54·0%) participants randomised to CT coronary angiography and 530 (60·8%) participants with standard of care alone (adjusted hazard ratio 0·81 (95% confidence interval, 0·72 to 0·92), P=0·001). However, there were no overall differences in coronary revascularisation, medication use for acute coronary syndrome or subsequent preventative therapies between arms. Early CT coronary angiography was associated with slightly longer hospitalisation (median increase 0·21 (95% confidence interval 0·05 to 0·40) days from median hospital stay of 2.0 to 2.2 days).
Conclusions: In intermediate risk patients with suspected acute coronary syndrome, early CT coronary angiography did not alter overall coronary therapeutic interventions or one-year clinical outcomes, but reduced rates of invasive angiography whilst modestly increasing length of hospital stay. These findings do not support the routine use of early CT coronary angiography in intermediate-risk patients with acute chest pain.