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  • Coronary CT and timing of invasive coronary angiography in patients ≥75 years old with non-ST segment elevation acute coronary syndromes

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Coronary artery disease
Original research
Coronary CT and timing of invasive coronary angiography in patients ≥75 years old with non-ST segment elevation acute coronary syndromes
  1. Hanna Ratcovich1,
  2. Golnaz Sadjadieh1,
  3. Jesper J Linde1,
  4. Francis R Joshi1,
  5. Henning Kelbæk2,
  6. Klaus F Kofoed1,
  7. Lars Køber1,
  8. Peter Riis Hansen3,
  9. Christian Torp-Pedersen4,
  10. Hanne Elming2,
  11. Gunnar Hilmar Gislason3,
  12. Dan Eik Høfsten1,
  13. Thomas Engstrøm1,
  14. Lene Holmvang1
  1. 1 Rigshospitalet, Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
  2. 2 Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Denmark
  3. 3 Department of Cardiology, Gentofte University Hospital, Hellerup, Denmark
  4. 4 Department of Clinical Investigation and Cardiology, Nordsjællands Hospital, Hillerød, Denmark
  1. Correspondence to Dr Hanna Ratcovich, Rigshospitalet, Department of Cardiology, Copenhagen University Hospital, Copenhagen 2100, Denmark; hanna.ratcovich{at}gmail.com

Abstract

Background The ability of coronary CT angiography (cCTA) to rule out significant coronary artery disease (CAD) in older patients with non-ST segment elevation acute coronary syndromes (NSTEACS) is unclear since valid cCTA analysis may be limited by extensive coronary artery calcification. In addition, the effect of very early invasive coronary angiography (ICA) with possible revascularisation is debated.

Methods This is a posthoc analysis of patients ≥75 years included in the Very Early vs Standard Care Invasive Examination and Treatment of Patients with Non-ST-Segment Elevation Acute Coronary Syndrome Trial. cCTA was performed prior to the ICA. The diagnostic accuracy of cCTA was investigated. Presence of a coronary artery stenosis ≥50% by subsequent ICA was used as reference. Patients were randomised to a very early (within 12 hours of diagnosis) or a standard ICA (within 48–72 hours of diagnosis). The primary composite endpoint was 5-year all-cause mortality, non-fatal recurrent myocardial infarction or hospital admission for refractory myocardial ischaemia or heart failure.

Results Of 452 (21%) patients ≥75 years, 161 (35.6%) underwent cCTA. 19% of cCTAs excluded significant CAD. The negative predictive value (NPV) of cCTA was 94% (95% CI 79 to 99) and the sensitivity 98% (95% CI 94 to 100). No significant differences in the frequency of primary endpoints were seen in patients randomised to very early ICA (at 5-year follow-up, n=100 (46.9%) vs 122 (51.0%), log-rank p=0.357).

Conclusion In patients ≥75 years with NSTEACS, cCTA before ICA showed a high NPV. A very early ICA <12 hours of diagnosis did not significantly improve long-term clinical outcomes.

  • acute coronary syndrome

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

https://doi.org/10.1136/heartjnl-2022-321640

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

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    Footnotes

    • Twitter @HRatcovich

    • Contributors (1) Conception, design and responsible for he overall content as the guarantator: HR, LH. (2) Analysis and interpretation of data: HR, GS, TE, LH. (3) Revision of the manuscript for important intellectual content: HR, GS, JJL, FRJ, HK, KFK, LK, PRH, CT-P, HE, GHG, DEH, TE, LH. (4) Final approval of the manuscript submitted: HR, GS, JJL, FRJ, HK, KFK, LK, PRH, CT-P, HE, GHG, DEH, TE, LH.

    • Funding Dr Hanna Ratcovich has received research grants from Copenhagen University Hospital Rigshospitalet’s Research Foundation for her salary during this work.

    • Competing interests None declared.

    • 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.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.