Impact of smoking in patients with suspected coronary artery disease in the randomised DISCHARGE trial

Massimo Mancone, Aldo J Vázquez Mézquita, Lucia Ilaria Birtolo, Pal Maurovich-Horvat, Klaus F Kofoed, Theodora Benedek, Patrick Donnelly, Jose Rodriguez-Palomares, Andrejs Erglis, Cyril Štěchovský, Gintare Šakalytė, Nada Čemerlić Ađić, Matthias Gutberlet, Ignacio Diez, Gershan Davis, Elke Zimmermann, Cezary Kępka, Radosav Vidakovic, Marco Francone, Małgorzata Ilnicka-SuckielFabian Plank, Juhanni Knuuti, Rita Faria, Stephen Schröder, Colin Berry, Luca Saba, Balazs Ruzsics, Nina Rieckmann, Christine Kubiak, Kristian Schultz Hansen, Jaqueline Müller-Nordhorn, Bela Merkely, Per E Sigvardsen, Imre Benedek, Clare Orr, Filipa Xavier Valente, Ligita Zvaigzne, Vojtěch Suchánek, Antanas Jankauskas, Filip Ađić, Michael Woinke, Stephen Keane, Ignacio Lecumberri, Erica Thwaite, Mariusz Kruk, Vladimir Jovanovic, Donata Kuśmierz, Gudren Feuchtner, Mikko Pietilä, Vasco Gama Ribeiro, Tanja Drosch, Christian Delles, Vitanio Palmisano, Michael Fisher, Zsófia D Drobni, Charlotte Kragelund, Rosca Aurelian, Stephanie Kelly, Bruno Garcia Del Blanco, Ainhoa Rubio, Melinda Boussoussou, Jens D Hove, Ioana Rodean, Susan Regan, Hug Cuéllar Calabria, Dávid Becker, Linnea Larsen, Roxana Hodas, Adriane E Napp, Robert Haase, Sarah Feger, Mahmoud Mohamed, Konrad Neumann, Henryk Dreger, Matthias Rief, Viktoria Wieske, Pamela S Douglas, Melanie Estrella, Maria Bosserdt, Peter Martus, Lina M Serna-Higuita, Jonathan D Dodd, Marc Dewey

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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.

Original languageEnglish
JournalEuropean Radiology
Pages (from-to)4127-4141
Number of pages15
ISSN0938-7994
DOIs
Publication statusPublished - 2024

Bibliographical note

© 2023. The Author(s), under exclusive licence to European Society of Radiology.

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