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Non-invasive imaging cuts needless angiography rate

ESC Congress News 2016 - Rome, Italy

Hot Line Session Results

Non-Invasive Imaging


Patients with suspected CHD whose care was guided by cardiovascular magnetic resonance (CMR) had significantly less unnecessary angiography than those whose care was led by guidelines. The study, which was described in a Hot Line presentation yesterday, did find, however, that CMR was not superior to myocardial perfusion scintigraphy (MPS).

The Clinical Evaluation of Magnetic Resonance Imaging in Coronary Heart Disease 2 (CE-MARC 2) trial results, also published in JAMA, could have implications for referral rates for invasive coronary angiography and potentially for costs.

Principal investigator John Greenwood from the University of Leeds, UK said: ‘Rates of invasive angiography are considered too high among patients with suspected CHD. Our findings now show that both CMR and MPS significantly reduced rates of unnecessary angiography compared to guideline-directed care, with no penalty in terms of major adverse cardiovascular events. This suggests that functional imaging should be adopted on a wider basis, even in high-risk patient subgroups.’

Early diagnostic pathways in patients with suspected CHD commonly use invasive CA - and this despite wide availability and recommendations for non-invasive imaging in international guidelines.

In explaining the background to the study, Greenwood said that evidence from large populations presenting with chest pain has confirmed that most will not have significant obstructive CHD. One large US study, for example, reported that approximately 60% of elective cardiac catheterisations found no obstructive CHD.

The CE-MARC 2 trial thus aimed to compare CMR, guidelines (which were those of the UK’s National Institute for Health and Care Excellence, NICE) or MPS in reducing unnecessary angiography in suspected CHD. The study also considered if a CMR approach reduced patient risk and made financial savings.

Between November 2012 and March 2015, 1202 symptomatic patients from six UK hospitals with suspected CHD were recruited. They were randomly assigned to care management according to the NICE guidelines (n=240), to care based on the results of CMR (n=481), or MPS testing (n=481). The primary endpoint was unnecessary angiography as defined by the absence of significant stenosis measured by FFR or quantitative CA.

Those assigned to the NICE group with a low likelihood of CHD (10-29%) were allocated to cardiac computed tomography (CCT); those with an intermediate likelihood (30%-60%) to MPS; and those with a high likelihood directly to CA.

Results showed that 22% of study subjects had coronary angioplasty within 12 months. In the NICE guidelines group 43% had  invasive CA, 18% CMR and 16% MPS.

A CMR-guided strategy did significantly reduce unnecessary angiography when compared with the NICE guided care.

However, there was no significant difference from an MPS-guided strategy.

There were no statistically significant differences between the three groups for the secondary endpoints of MACE and positive angiography. The latter was observed in NICE as 12.1%, CMR 9.8% and MPS 8.7%.

Greenwood said: ‘These results show that a broader use of functional imaging - CMR or MPS - in low, intermediate and high risk patient groups could reduce the rates of invasive angiography which will ultimately show no obstructive coronary disease.

‘In addition, CE-MARC and CE-MARC 2 further support the role of CMR as an alternative to MPS for the diagnosis and management of patients with suspected CHD.’

However, there was no significant difference from an MPS-guided strategy.

There were no statistically significant differences between the three groups for the secondary endpoints of MACE and positive angiography. The latter was observed in NICE as 12.1%, CMR 9.8% and MPS 8.7%.

Greenwood said: ‘These results show that a broader use of functional imaging - CMR or MPS - in low, intermediate and high risk patient groups could reduce the rates of invasive angiography which will ultimately show no obstructive coronary disease.

‘In addition, CE-MARC and CE-MARC 2 further support the role of CMR as an alternative to MPS for the diagnosis and management of patients with suspected CHD.’ 

 

Click here to read other scientific highlights in the full edition of the Congress news.

Notes to editor

To access all the scientific resources from the sessions during the congress, visit ESC Congress 365.  

About the European Society of Cardiology

The European Society of Cardiology brings together health care professionals from more than 120 countries, working to advance cardiovascular medicine and help people lead longer, healthier lives.

About ESC Congress 2016

ESC Congress is the world’s largest gathering of cardiovascular professionals contributing to global awareness of the latest clinical trials and breakthrough discoveries. ESC Congress 2016 takes place 27 to 31 August at the Fiera di Roma in Rome, Italy. The full scientific programme is here.