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Clinical decision aids and computed tomography coronary angiography in patients with suspected acute coronary syndrome
  1. Kang-Ling Wang1,2,3,
  2. Caelan Taggart1,4,
  3. Michael McDermott1,
  4. Rachel O'Brien5,
  5. Katherine Oatey6,
  6. Liza Keating7,
  7. Robert F Storey8,9,
  8. Dirk Felmeden10,
  9. Nick Curzen11,12,
  10. Attila Kardos13,
  11. Carl Roobottom14,
  12. Jason Smith15,
  13. Steve Goodacre16,
  14. David E Newby1,
  15. Alasdair J Gray5,17
  16. on behalf of the RAPID-CTCA Investigators
    1. 1Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
    2. 2School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
    3. 3General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
    4. 4Department of Cardiology, Royal Infirmary of Edinburgh, Edinburgh, UK
    5. 5EMERGE (Emergency Medicine Research Group, Edinburgh), Royal Infirmary of Edinburgh, Edinburgh, UK
    6. 6Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
    7. 7Department of Emergency Medicine, Royal Berkshire NHS Foundation Trust, Reading, UK
    8. 8Division of Clinical Medicine, University of Sheffield, Sheffield, UK
    9. 9NIHR Sheffield Biomedical Research Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
    10. 10Department of Cardiology, Torbay and South Devon NHS Foundation Trust, Torquay, UK
    11. 11Faculty of Medicine, University of Southampton, Southampton, UK
    12. 12Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
    13. 13TCRG (Translational Cardiovascular Research Group), Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
    14. 14Department of Radiology, University Hospitals Plymouth NHS Trust, Plymouth, UK
    15. 15Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
    16. 16School of Health and Related Research, University of Sheffield, Sheffield, UK
    17. 17Usher Institute, University of Edinburgh, Edinburgh, UK
    1. Correspondence to Dr Kang-Ling Wang, Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SB, UK; k.l.wang{at}ed.ac.uk

    Abstract

    Background The HEART score, the T-MACS model and the GRACE score support early decision-making for acute chest pain, which could be complemented by CT coronary angiography (CTCA). However, their performance has not been directly compared.

    Methods In this secondary analysis of a multicentre randomised controlled trial of early CTCA in intermediate-risk patients with suspected acute coronary syndrome, C-statistics and performance metrics (using the predefined cut-offs) of clinical decision aids and CTCA, alone and then in combination, for the index hospital diagnosis of acute coronary syndrome and for 30-day coronary revascularisation were assessed in those who underwent CTCA and had complete data.

    Results Among 699 patients, 358 (51%) had an index hospital diagnosis of acute coronary syndrome, for which the C-statistic was higher for CTCA (0.80), followed by the T-MACS model (0.78), the HEART score (0.74) and the GRACE score (0.60). The negative predictive value was higher for the absence of coronary artery disease on CTCA (0.90) or a T-MACS estimate of <0.05 (0.83) than a HEART score of <4 (0.81) and a GRACE score of <109 (0.55). For 30-day coronary revascularisation, CTCA had the greatest C-statistic (0.80) with a negative predictive value of 0.96 and 0.92 in the absence of coronary artery disease and obstructive coronary artery disease, respectively. The combination of the T-MACS estimates and the CTCA findings was most discriminative for the index hospital diagnosis of acute coronary syndrome (C-statistic, 0.88) and predictive of 30-day coronary revascularisation (C-statistic, 0.85). No patients with a T-MACS estimate of <0.05 and normal coronary arteries had acute coronary syndrome during index hospitalisation or underwent coronary revascularisation within 30 days.

    Conclusions In intermediate-risk patients with suspected acute coronary syndrome, the T-MACS model combined with CTCA improved discrimination of the index hospital diagnosis of acute coronary syndrome and prediction of 30-day coronary revascularisation.

    Trial registration number NCT02284191.

    • clinical

    Data availability statement

    Data are available upon reasonable request. De-identified data are available on reasonable request which should be submitted to the chief investigator (AJG) of the RAPID-CTCA trial.

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    Data availability statement

    Data are available upon reasonable request. De-identified data are available on reasonable request which should be submitted to the chief investigator (AJG) of the RAPID-CTCA trial.

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    Footnotes

    • Handling editor Edward Carlton

    • Contributors Concept and design—KLW and CT. Analysis or interpretation of data—KLW, CT, MM, DEN and AJG. Drafting of the manuscript—KLW, DEN and AJG. Critical revision of the manuscript for important intellectual content—CT, MM, RO'B, KO, LK, RFS, DF, NC, AK, CR, JS and SG. Obtained funding—DEN and AJG. Administrative, technical or material support—RO'B and KO. Supervision—LK, RFS, DF, NC, AK, CR, JS, SG, DEN and AJG. Study guarantor—KLW.

    • Funding The RAPID-CTCA trial was funded by the UK National Institute for Health and Care Research Health Technology Assessment Programme (13/04/108).

    • Disclaimer The funders played no role in the design and conduct of the study, collection, management, analysis and interpretation of the data, preparation, review or approval of the manuscript, and decision to submit the manuscript for publication.

    • Competing interests KO reports research grants from the British Heart Foundation, the Jon Moulton Charity Trust and University of Edinburgh. RFS reports research grants from AstraZeneca and Cytosorbents; consulting fees and/or honoraria from Alfasigma, AstraZeneca, Chiesi, Cytosorbents, Daiichi-Sankyo, Idorsia, Novartis, Novo Nordisk, Pfizer, PhaseBio and Tabuk. NC reports research grants from Beckman Coulter, Boston Scientific, HeartFlow and Haemonetics; consulting fees and/or honoraria from Abbott, Boston Scientific and Edwards Lifesciences; travel sponsorship from Abbott, Biosensors and Edwards Lifesciences. AK reports honoraria from the TomTec Imaging Systems. CR reports honoraria from GE HealthCare.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

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