OBJECTIVES: The aim of the CATCH (CArdiac cT in the treatment of acute CHest pain) trial was to investigate the long-term clinical impact of a coronary computed tomographic angiography (CTA)-guided treatment strategy in patients with recent acute-onset chest pain compared to standard care. The prognostic implications of a coronary CTA-guided treatment strategy have not been compared in a randomized fashion to standard care in patients referred for acute-onset chest pain.
METHODS: Patients with acute chest pain but normal electrocardiograms and troponin values were randomized to treatment guided by either coronary CTA or standard care (bicycle exercise electrocardiogram or myocardial perfusion imaging). In the coronary CTA-guided group, a functional test was included in cases of non-diagnostic coronary CTA images or coronary stenosis of borderline severity. The primary endpoint was a composite of cardiac death, myocardial infarction (MI), hospitalization for unstable angina pectoris (UAP), late symptom-driven revascularizations, and readmission for chest pain.
RESULTS: We randomized 299 patients to coronary CTA-guided strategy and 301 to standard care. After inclusion, 24 patients withdrew their consent. The median (interquartile range) follow-up duration was 18.7 (range 16.8 to 20.1) months. In the coronary CTA-guided group, 30 patients (11%) had a primary endpoint versus 47 patients (16%) in the standard care group (p = 0.04; hazard ratio (HR): 0.62 [95% confidence interval: 0.40 to 0.98]). A major adverse cardiac event (cardiac death, MI, hospitalization for UAP, and late symptom-driven revascularization) was observed in 5 patients (2 MIs, 3 UAPs) in the coronary CTA-guided group versus 14 patients (1 cardiac death, 7 MIs, 5 UAPs, 1 late symptom-driven revascularization) in the standard care group (p = 0.04; HR: 0.36 [95% CI: 0.16 to 0.95). Differences in cardiac death and MI (8 vs. 2) were insignificant (p = 0.06).
CONCLUSIONS: A coronary CTA-guided treatment strategy appears to improve clinical outcome in patients with recent acute-onset chest pain and normal electrocardiograms and troponin values compared to standard care with a functional test.
COMPETENCY IN MEDICAL KNOWLEDGE: Among patients hospitalized for acute chest pain, who have normal concentrations of plasma troponins and series of electrocardiograms without signs of ischemia (low-risk unstable angina), an out-patient coronary CTA-guided diagnostic evaluation strategy appears to improve the long-term clinical outcome, compared to standard evaluation with a functional test.
TRANSLATIONAL OUTLOOK: Previous randomized trials on the clinical implementation of coronary CTA have focused on logistical, safety and economic aspects of patient management in the emergency department. The CATCH trial monitored long-term clinical outcome and therefore adds incremental evidence of a beneficial clinical value for patients with chest pain undergoing first line diagnostic evaluation with coronary CTA. However, because the patient population studied in the CATCH trial was evaluated in a post-discharge outpatient setting, the long-term clinical value of early triage with coronary CTA in the ED should be investigated in other randomized studies.