Rasmussen Laust Dupont, Schmidt Samuel Emil, Knuuti Juhani, Vrints Christiaan, Bøttcher Morten, Foldyna Borek, Williams Michelle C, Newby David E, Douglas Pamela S, Winther Simon
Department of Cardiology, Gødstrup Hospital, Herning, Denmark.
Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.
Eur Heart J. 2025 Feb 3;46(5):473-483. doi: 10.1093/eurheartj/ehae742.
Whether index testing using coronary computed tomography angiography (CTA) improves outcomes in stable chest pain is debated. The risk factor weighted clinical likelihood (RF-CL) model provides likelihood estimation of obstructive coronary artery disease. This study investigated the prognostic effect of coronary CTA vs. usual care by RF-CL estimates.
Large-scale studies randomized patients (N = 13 748) with stable chest pain to coronary CTA as part of the initial work-up in addition to or instead of usual care including functional testing. Patients were stratified according to RF-CL estimates [RF-CL: very-low (≤5%), low (>5%-15%), and moderate/high (>15%)]. The primary endpoint was myocardial infarction or death at 3 years.
The primary endpoint occurred in 313 (2.3%) patients. Event rates were similar in patients allocated to coronary CTA vs. usual care [risk difference (RD) 0.3%, hazard ratio (HR) 0.84 (95% CI 0.67-1.05)]. Overall, 33%, 44%, and 23% patients had very-low, low, and moderate/high RF-CL. Risk was similar in patients with very low and moderate/high RF-CL allocated to coronary CTA vs. usual care [very low: RD 0.3%, HR 1.27 (0.74-2.16); moderate/high: RD 0.5%, HR 0.88 (0.63-1.23)]. Conversely, patients with low RF-CL undergoing coronary CTA had lower event rates [RD 0.7%, HR 0.67 (95% CI 0.47-0.97)]. The number needed to test using coronary CTA to prevent one event within 3 years was 143.
Despite an overall good prognosis, low RF-CL patients have reduced risk of myocardial infarction or death when allocated to coronary CTA vs. usual care. Risk is similar in patients with very-low and moderate/high likelihood.
使用冠状动脉计算机断层扫描血管造影（CTA）进行指标检测能否改善稳定型胸痛患者的预后存在争议。风险因素加权临床可能性（RF-CL）模型可提供阻塞性冠状动脉疾病的可能性估计。本研究通过RF-CL估计值探讨了冠状动脉CTA与常规治疗相比的预后效果。
大规模研究将13748例稳定型胸痛患者随机分为冠状动脉CTA组，作为初始检查的一部分，此外还包括或替代包括功能测试在内的常规治疗。患者根据RF-CL估计值进行分层[RF-CL：极低（≤5%）、低（>5%-15%）和中/高（>15%）]。主要终点是3年时的心肌梗死或死亡。
313例（2.3%）患者发生了主要终点事件。分配至冠状动脉CTA组与常规治疗组的患者事件发生率相似[风险差异（RD）0.3%，风险比（HR）0.84（95%CI 0.67-1.05）]。总体而言，33%、44%和23%的患者RF-CL极低、低和中/高。分配至冠状动脉CTA组与常规治疗组的RF-CL极低和中/高的患者风险相似[极低：RD 0.3%，HR 1.27（0.74-2.16）；中/高：RD 0.5%，HR 0.88（0.63-1.23）]。相反，接受冠状动脉CTA检查的RF-CL低的患者事件发生率较低[RD 0.7%，HR 0.67（95%CI 0.47-0.97）]。使用冠状动脉CTA检测以在3年内预防1例事件所需的例数为143。
尽管总体预后良好，但与常规治疗相比，RF-CL低的患者分配至冠状动脉CTA组时，心肌梗死或死亡风险降低。可能性极低和中/高的患者风险相似。
