Author + information
- Received March 20, 2019
- Revision received August 30, 2019
- Accepted September 3, 2019
- Published online November 11, 2019.
- Martijn W. Smulders, MDa,b,
- Bas L.J.H. Kietselaer, MD, PhDa,b,c,
- Joachim E. Wildberger, MD, PhDb,c,
- Pieter C. Dagnelie, PhDb,d,
- Hans-Peter Brunner–La Rocca, MDa,b,
- Alma M.A. Mingels, PhDe,
- Yvonne J.M. van Cauteren, MDa,b,c,
- Ralph A.L.J. Theunissen, MDa,
- Mark J. Post, MD, PhDb,f,
- Simon Schalla, MD, PhDa,b,c,
- Sander M.J. van Kuijk, PhDg,
- Marco Das, MD, PhDb,c,h,
- Raymond J. Kim, MDi,
- Harry J.G.M. Crijns, MD, PhDa,b and
- Sebastiaan C.A.M. Bekkers, MD, PhDa,b,c,∗ ()
- aDepartment of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands
- bCardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
- cDepartment of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
- dDepartment of Internal Medicine, Maastricht University, Maastricht, the Netherlands
- eDepartment of Clinical Chemistry, Maastricht University Medical Center, Maastricht, the Netherlands
- fDepartment of Physiology, Maastricht University, Maastricht, the Netherlands
- gDepartment of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, the Netherlands
- hDepartment of Diagnostic and Interventional Radiology, Helios Klinikum, Duisburg, Germany
- iDuke Cardiovascular Magnetic Resonance Center, Duke University Medical Center, Durham, North Carolina
- ↵∗Address for correspondence:
Dr. Sebastiaan C.A.M. Bekkers, Department of Cardiology, Maastricht University Medical Center, P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, the Netherlands.
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.
- cardiovascular magnetic resonance
- computed tomographic angiography
- high-sensitive cardiac troponin
- invasive coronary angiography
- non–ST-segment elevation myocardial infarction
This work was supported by the Netherlands Heart Foundation (grant 2014T051 to Dr. Smulders). Drs. Wildberger, van Cauteren, Schalla, and Bekkers have received funding from the Weijerhorst Foundation. Dr. Kietselaer has received unrestricted grants from AstraZeneca and Boehringer Ingelheim. Dr. Wildberger has received institutional grants from Agfa, Bayer, GE, Philips, Bracco, and Siemens; and has received personal fees (Speakers Bureau) from Siemens and Bayer. Dr. Brunner–La Rocca has received unrestricted grants from Novartis Pharma, Vifor Pharma, and Roche Diagnostics. Dr. Mingels has received nonfinancial support from Abbott Diagnostics. Dr. Post has received funding by the Center for Translational Molecular Medicine, project EMINENCE (grant 01C-204). Dr. Das has received institutional grants from Siemens, Philips, and Bayer; and has received personal fees (Speakers Bureau) from Siemens, Cook, and Bayer. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 20, 2019.
- Revision received August 30, 2019.
- Accepted September 3, 2019.
- 2019 American College of Cardiology Foundation
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