Why the study?
Suspected cardiac chest pain guidelines have used historical risk stratification tools advocating first-line invasive coronary angiography, but it was unknown whether different management strategies affect medium-term cardiovascular events and quality of life.
Does first-line functional imaging (CMR or SPECT) improve 3-year MACE rates or quality of life compared to NICE guideline-directed care in patients with suspected stable cardiac chest pain?
Does first-line functional imaging (CMR or SPECT) improve 3-year MACE rates or quality of life compared to NICE guideline-directed care in patients with suspected stable cardiac chest pain?
In patients with suspected stable angina, a NICE guideline-directed care strategy did not significantly reduce 3-year MACE or improve quality of life compared to functional imaging with CMR or SPECT, despite leading to a fourfold increase in invasive coronary angiography referrals.
Similar 3-year outcomes across strategies; leaves open optimal initial testing for suspected stable angina.
AIMS: Guidelines for suspected cardiac chest pain have used historical risk stratification tools, advocating invasive coronary angiography (ICA) first-line in those at highest risk. We aimed to determine whether different strategies to manage suspected stable angina affected medium-term cardiovascular event rates and patient-reported quality of life (QoL) measures. METHODS: CE-MARC 2, a three-arm parallel group trial, randomised patients with suspected stable cardiac chest pain and a Duke Clinical pretest likelihood of coronary artery disease between 10% and 90%. Patients were randomised to either first-line cardiovascular magnetic resonance (CMR), single-photon emission computed tomography (SPECT) or the UK National Institute for Health and Care Excellence (NICE) CG95 (2010) guidelines-directed care. For the three arms, 1-year and 3-year first major adverse cardiovascular event (MACE) rates and QoL assessed by the Seattle Angina Questionnaire, Short Form 12 (V.12) Questionnaire and EuroQol-5 Dimension Questionnaire were recorded. RESULTS: 1202 patients were randomised to CMR (n=481), SPECT (n=481) and NICE (n=240). Forty-two patients (18 CMR, 18 SPECT, 6 NICE) experienced one or more MACEs. The percentage rates (95% CIs) of MACE in the CMR, SPECT and NICE groups at 3 years were 3.7% (2.4%, 5.8%), 3.7% (2.4%, 5.8%) and 2.1% (0.9%, 4.8%), respectively. QoL scores did not significantly differ across domains. CONCLUSION: Despite a fourfold increase in referrals for ICA, the NICE CG95 (2010) guidelines risk-stratified care strategy did not significantly reduce 3-year MACE or improve QoL, as compared with functional imaging with CMR or SPECT. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT01664858).
No takes yet. Share an insight, caveat, or question.
Everett et al. (2023) studied this question.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: