Cardiac computed tomography guided treatment strategy in patients with recent acute-onset chest pain ☆ , ☆☆ Results from the randomised, controlled trial: CArdiac cT in the treatment of acute CHest pain (CATCH) Jesper James Linde a, ⁎, Klaus Fuglsang Kofoed b,c , Mathias Sørgaard b , Henning Kelbæk b , Gorm Boje Jensen a , Walter Bjørn Nielsen a , Jens Dahlgaard Hove a a Department of Cardiology, Hvidovre Hospital, University of Copenhagen, Denmark b Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Denmark c Department of Radiology, The Diagnostic Centre, Rigshospitalet, University of Copenhagen, Denmark abstract article info Article history: Received 1 May 2013 Received in revised form 25 July 2013 Accepted 3 August 2013 Available online 14 August 2013 Keywords: Cardiac computed tomographic angiography Ischaemic heart disease Acute coronary syndrome Angina pectoris Objectives: In patients admitted on suspicion of acute coronary syndrome, with normal electrocardiogram and troponines, we evaluated the clinical impact of a Coronary CT angiography (CCTA)-strategy on referral rate for invasive coronary angiography (ICA), detection of significant coronary stenoses (positive predictive value [PPV]) and subsequent revascularisations, as compared to a function-based strategy (standard care). Secondarily we assessed intermediate term clinical events. Methods and results: We randomised 600 patients to a CCTA-guided strategy (299 patients) or standard care (301 patients). In the CCTA-guided group referral for ICA required a coronary stenosis N 70% or N 50% in the left main, and for intermediate stenoses (50–70%), a stress test was used. A significant stenosis on ICA was defined as a stenosis ≥70% or reduced FFR ≤0.75 in intermediate stenoses (50–70%). Referral rate for ICA was 17% with CCTA vs. 12% with standard care (p = 0.1). ICA confirmed significant coronary artery stenoses in 12% vs. 4% (p = 0.001), and 10% vs. 4% were subsequently revascularised (p = 0.005). PPV for the detection of significant stenoses was 71% with CCTA vs 36% with standard care (p = 0.001). Clinical events (cardiac death, myocardial infarction, unstable angina pectoris, revascularisation and readmission for chest pain), during 120 days of follow-up, were recorded in 8 patients (3%) in the CCTA-guided group vs. 15 patients (5%) in the standard care group (p = 0.1). Conclusion: In patients with recent acute-onset chest pain, a CCTA-guided diagnostic strategy improves PPV for the detection of significant coronary stenoses, and increases the frequency of revascularisations, when compared to a conventional functional approach. © 2013 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Diagnostic evaluation of patients hospitalised under suspicion of acute coronary syndrome (ACS) with successive normal electrocardio- grams (ECG's), normal plasma-troponins and without in-hospital recurrence of chest pain, remains an important clinical challenge. In accordance with the European Society of Cardiology (ESC) guidelines for the managements of Non-ST-elevation (NSTE)-ACS [1], functional- based tests, such as exercise bicycle testing and/or myocardial perfusion imaging (MPI) with single-photon emission computed tomography (SPECT), may be used to identify patients with haemodynamically significant coronary artery disease (CAD). However, whereas these methods may identify patients with myocardial ischaemia, they do not provide coronary patho-anatomic information. Nevertheless, detailed visualisation of anatomical location, lesion characteristics and severity of coronary artery stenoses is of paramount importance for identifying patients, who will benefit from invasive coronary angio- graphy (ICA) and revascularisation. Cardiac computed tomographic angiography (CCTA) has emerged as a new diagnostic test providing detailed information about coronary patho-anatomy, and ESC guidelines state that CCTA “should be consid- ered as an alternative to invasive angiography to exclude ACS” [1]. In a International Journal of Cardiology 168 (2013) 5257–5262 ☆ Responsibility: All authors take responsibility for all aspects of the reliability and free- dom from bias of the data presented and their discussed interpretation. ☆☆ Funding: Dr. JJL was supported by a grant from the Danish Heart Foundation [grant number 12-04-R90_A3921-22718]. In addition this work was supported by the John and Birthe Meyer Foundation, the AP Møller and Chastine Mc-Kinney Møller Foundation and the Toyota Foundation. ⁎ Corresponding author at: Department of Cardiology 253, Hvidovre University Hospital, Kettegård alle 30, 2650 Hvidovre, Denmark. Tel.: +45 26797774; fax: +45 38623755. E-mail address: jesper_linde@hotmail.com (J.J. Linde). 0167-5273/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.08.020 Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard