학술논문
Impact of smoking in patients with suspected coronary artery disease in the randomised DISCHARGE trial
Document Type
Original Paper
Author
Mancone, Massimo; Mézquita, Aldo J. Vázquez; Birtolo, Lucia Ilaria; Maurovich-Horvat, Pal; Kofoed, Klaus F.; Benedek, Theodora; Donnelly, Patrick; Rodriguez-Palomares, Jose; Erglis, Andrejs; Štěchovský, Cyril; Šakalytė, Gintare; Ađić, Nada Čemerlić; Gutberlet, Matthias; Diez, Ignacio; Davis, Gershan; Zimmermann, Elke; Kępka, Cezary; Vidakovic, Radosav; Francone, Marco; Ilnicka-Suckiel, Małgorzata; Plank, Fabian; Knuuti, Juhanni; Faria, Rita; Schröder, Stephen; Berry, Colin; Saba, Luca; Ruzsics, Balazs; Rieckmann, Nina; Kubiak, Christine; Hansen, Kristian Schultz; Müller-Nordhorn, Jaqueline; Merkely, Bela; Sigvardsen, Per E.; Benedek, Imre; Orr, Clare; Valente, Filipa Xavier; Zvaigzne, Ligita; Suchánek, Vojtěch; Jankauskas, Antanas; Ađić, Filip; Woinke, Michael; Keane, Stephen; Lecumberri, Ignacio; Thwaite, Erica; Kruk, Mariusz; Jovanovic, Vladimir; Kuśmierz, Donata; Feuchtner, Gudren; Pietilä, Mikko; Ribeiro, Vasco Gama; Drosch, Tanja; Delles, Christian; Palmisano, Vitanio; Fisher, Michael; Drobni, Zsófia D.; Kragelund, Charlotte; Aurelian, Rosca; Kelly, Stephanie; del Blanco, Bruno Garcia; Rubio, Ainhoa; Boussoussou, Melinda; Hove, Jens D.; Rodean, Ioana; Regan, Susan; Calabria, Hug Cuéllar; Becker, Dávid; Larsen, Linnea; Hodas, Roxana; Napp, Adriane E.; Haase, Robert; Feger, Sarah; Mohamed, Mahmoud; Neumann, Konrad; Dreger, Henryk; Rief, Matthias; Wieske, Viktoria; Douglas, Pamela S.; Estrella, Melanie; Bosserdt, Maria; Martus, Peter; Serna-Higuita, Lina M.; Dodd, Jonathan D.; Dewey, Marc
Source
European Radiology. 34(6):4127-4141
Subject
Language
English
ISSN
1432-1084
Abstract
Objectives: To investigate if the effect of cardiac computed tomography (CT) vs. invasive coronary angiography (ICA) on cardiovascular events differs based on smoking status.Materials and methods: This pre-specified subgroup analysis of the pragmatic, prospective, multicentre, randomised DISCHARGE trial (NCT02400229) involved 3561 patients with suspected coronary artery disease (CAD). The primary endpoint was major adverse cardiovascular events (MACE: cardiovascular death, non-fatal myocardial infarction, or stroke). Secondary endpoints included an expanded MACE composite (MACE, transient ischaemic attack, or major procedure-related complications).Results: Of 3445 randomised patients with smoking data (mean age 59.1 years + / − 9.7, 1151 men), at 3.5-year follow-up, the effect of CT vs. ICA on MACE was consistent across smoking groups (p for interaction = 0.98). The percutaneous coronary intervention rate was significantly lower with a CT-first strategy in smokers and former smokers (p = 0.01 for both). A CT-first strategy reduced the hazard of major procedure-related complications (HR: 0.21, 95% CI: 0.03, 0.81; p = 0.045) across smoking groups. In current smokers, the expanded MACE composite was lower in the CT- compared to the ICA-first strategy (2.3% (8) vs 6.0% (18), HR: 0.38; 95% CI: 0.17, 0.88). The rate of non-obstructive CAD was significantly higher in all three smoking groups in the CT-first strategy.Conclusion: For patients with stable chest pain referred for ICA, the clinical outcomes of CT were consistent across smoking status. The CT-first approach led to a higher detection rate of non-obstructive CAD and fewer major procedure-related complications in smokers.Clinical relevance statement: This pre-specified sub-analysis of the DISCHARGE trial confirms that a CT-first strategy in patients with stable chest pain referred for invasive coronary angiography with an intermediate pre-test probability of coronary artery disease is as effective as and safer than invasive coronary angiography, irrespective of smoking status.Trial registration: ClinicalTrials.gov NCT02400229.Key Points: • No randomised studies have assessed smoking status on CT effectiveness in symptomatic patients referred for invasive coronary angiography.• A CT-first strategy results in comparable adverse events, fewer complications, and increased coronary artery disease detection, irrespective of smoking status.• A CT-first strategy is safe and effective for stable chest pain patients with intermediate pre-test probability for CAD, including never smokers.Graphical Abstract: