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Randomized Controlled Trial
. 2024 Apr 1;9(4):346-356.
doi: 10.1001/jamacardio.2024.0001.

Age and Computed Tomography and Invasive Coronary Angiography in Stable Chest Pain: A Prespecified Secondary Analysis of the DISCHARGE Randomized Clinical Trial

DISCHARGE Trial Group; Maria Bosserdt  1 , Lina M Serna-Higuita  2 , Gudrun Feuchtner  3 , Bela Merkely  4 , Klaus F Kofoed  5 , Theodora Benedek  6   7 , Patrick Donnelly  8 , José Rodriguez-Palomares  9   10 , Andrejs Erglis  11   12 , Cyril Štechovský  13 , Gintare Šakalyte  14   15 , Nada Cemerlic Adic  16   17 , Matthias Gutberlet  18 , Jonathan D Dodd  19   20 , Ignacio Diez  21 , Gershan Davis  22   23 , Elke Zimmermann  1 , Cezary Kepka  24 , Radosav Vidakovic  25   26 , Marco Francone  27   28 , Malgorzata Ilnicka-Suckiel  29 , Fabian Plank  3   30 , Juhani Knuuti  31 , Rita Faria  32 , Stephen Schröder  33 , Colin Berry  34   35 , Luca Saba  36 , Balazs Ruzsics  37   38 , Nina Rieckmann  39 , Christine Kubiak  40 , Kristian Schultz Hansen  41 , Jacqueline Müller-Nordhorn  42 , Bálint Szilveszter  4 , Per E Sigvardsen  5 , Imre Benedek  43 , Clare Orr  8 , Filipa Xavier Valente  9   10 , Ligita Zvaigzne  44 , Vojtech Suchánek  45 , Antanas Jankauskas  46 , Filip Adic  16   17 , Michael Woinke  47 , Mark Hensey  48 , Iñigo Lecumberri  49 , Erica Thwaite  50 , Michael Laule  51 , Mariusz Kruk  24 , Aleksandar N Neskovic  25   26 , Massimo Mancone  52 , Donata Kusmierz  53 , Mikko Pietilä  54   55 , Vasco Gama Ribeiro  32 , Tanja Drosch  33 , Christian Delles  34 , Maurizio Porcu  56 , Michael Fisher  37   57   38 , Melinda Boussoussou  4 , Charlotte Kragelund  58 , Rosca Aurelian  59 , Stephanie Kelly  8 , Bruno Garcia Del Blanco  9 , Ainhoa Rubio  21 , Pál Maurovich-Horvat  4   60 , Jens D Hove  61   62 , Ioana Rodean  43 , Susan Regan  8 , Hug Cuellar-Calabria  63 , Levente Molnár  4 , Linnea Larsen  64 , Roxana Hodas  6 , Adriane E Napp  1 , Robert Haase  1 , Sarah Feger  1 , Mahmoud Mohamed  1 , Konrad Neumann  39 , Henryk Dreger  65   66 , Matthias Rief  1 , Viktoria Wieske  1 , Melanie Estrella  1 , Peter Martus  2 , Harold C Sox  67 , Marc Dewey  1   66   68   69
Affiliations
Randomized Controlled Trial

Age and Computed Tomography and Invasive Coronary Angiography in Stable Chest Pain: A Prespecified Secondary Analysis of the DISCHARGE Randomized Clinical Trial

DISCHARGE Trial Group et al. JAMA Cardiol. .

Abstract

Importance: The effectiveness and safety of computed tomography (CT) and invasive coronary angiography (ICA) in different age groups is unknown.

Objective: To determine the association of age with outcomes of CT and ICA in patients with stable chest pain.

Design, setting, and participants: The assessor-blinded Diagnostic Imaging Strategies for Patients With Stable Chest Pain and Intermediate Risk of Coronary Artery Disease (DISCHARGE) randomized clinical trial was conducted between October 2015 and April 2019 in 26 European centers. Patients referred for ICA with stable chest pain and an intermediate probability of obstructive coronary artery disease were analyzed in an intention-to-treat analysis. Data were analyzed from July 2022 to January 2023.

Interventions: Patients were randomly assigned to a CT-first strategy or a direct-to-ICA strategy.

Main outcomes and measures: MACE (ie, cardiovascular death, nonfatal myocardial infarction, or stroke) and major procedure-related complications. The primary prespecified outcome of this secondary analysis of age was major adverse cardiovascular events (MACE) at a median follow-up of 3.5 years.

Results: Among 3561 patients (mean [SD] age, 60.1 [10.1] years; 2002 female [56.2%]), 2360 (66.3%) were younger than 65 years, 982 (27.6%) were between ages 65 to 75 years, and 219 (6.1%) were older than 75 years. The primary outcome was MACE at a median (IQR) follow-up of 3.5 (2.9-4.2) years for 3523 patients (99%). Modeling age as a continuous variable, age, and randomization group were not associated with MACE (hazard ratio, 1.02; 95% CI, 0.98-1.07; P for interaction = .31). Age and randomization group were associated with major procedure-related complications (odds ratio, 1.15; 95% CI, 1.05-1.27; P for interaction = .005), which were lower in younger patients.

Conclusions and relevance: Age did not modify the effect of randomization group on the primary outcome of MACE but did modify the effect on major procedure-related complications. Results suggest that CT was associated with a lower risk of major procedure-related complications in younger patients.

Trial registration: ClinicalTrials.gov Identifier: NCT02400229.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Bosserdt reported receiving funding from the European Commission and German Research Foundation outside the submitted work. Dr Merkely reported receiving personal fees from Abbott, AstraZeneca, Biotronik, Boehringer Ingelheim, CSL Behring, Daiichi Sankyo, Duke Clinical Research Institute, Medtronic, and Novartis and grants from Boston Scientific outside the submitted work. Dr Kofoed reported receiving grants from Canon Medical Systems, GE Healthcare, AP Møller og Hustru Chastine McKinney Møllers Fond, Novo Nordisk Foundation, and Research Council of Rigshopitalet during the conduct of the study. Dr Stechovsky reported receiving grants from European Commission Horizon 2020 during the conduct of the study. Dr Čemerlić Ađić reported receiving grants from the European Commission during the conduct of the study. Dr Gutberlet reported receiving speaker honorarium from Bayer, Siemens, and Edwards. Dr Dodd reported receiving grants from the European Commission, authorship fees from Elsevier, and being an associate editor for Radiology and editorial board member for Radiology Cardiothoracic Imaging. Dr Knuuti reported receiving grants from the European Commission and speaker/reviewer fees from GE Healthcare Study, Synektik Pharma, Boehringer Ingelheim, Lundbeck, Siemens Healthineers, Bayer, and Pfizer outside the submitted work. Dr Faria reported receiving grants from the European Commission during the conduct of the study. Dr Berry reported receiving grants from the European Union Institutional award; nonfinancial support from Abbott Vascular, AstraZeneca, Boehringer Ingelheim, Coroventis, HeartFlow, Menarini, MSD, Novartis, Servier, Siemens Healthcare, TherOx Inc, and Valo Health Consultancy; and research grant funding from the British Heart Foundation, Chief Scientist Office, Engineering and Physical Sciences Research Council, European Union, Medical Research Council, and UK Research and Innovation. Dr Ruzsics reported receiving grants from Royal Liverpool University Hospital during the conduct of the study. Drs Kubiak, Hansen, Szilveszter, Valente, Ađić, Maurovich-Horvat, Feger, and Wieske reported receiving funding from the European Commission Funding 7th Framework Programme during the conduct of the study. Dr Sigvardsen reported receiving personal fees from Novo Nordisk outside the submitted work. Dr Molnár reported receiving consultation fees from Abbott, Biotronik, and Medtronic outside the submitted work. Dr Napp reported receiving grants from the European Commission Funding 7th Framework Programme during the conduct of the study. Dr Rief reported receiving grants from the European Commission and Deutsche Forschungsgemeinschaft Radiomics during the conduct of the study. Dr Estrella reported receiving funding from the European Commission and German Research Foundation outside the submitted work. Dr Dewey reported receiving grants from the European Commission, German Research Foundation, the DFG Priority Programme Radiomics for the investigation of coronary plaque and coronary flow, and Berlin University Alliance; having a patent for dynamic perfusion analysis using fractal analysis; serving as publications chair for the European Society of Radiology; serving as editor of Cardiac CT; and offering hands-on courses on CT imaging. Institutional master research agreements exist with Siemens, General Electric, Philips, and Canon. The terms of these arrangements are managed by the legal department of Charité—Universitätsmedizin Berlin. No other disclosures were reported.

Figures

Figure.
Figure.. Cumulative Incidence of the Primary Outcome: Major Adverse Cardiovascular Events (MACE)
A, Cumulative incidence of MACE at a median follow-up of 3.5 years and Cox regression using P-spline. Interaction with study arm groups to evaluate the association of age on the hazard ratio with the risk of the primary outcome MACE (B) and major procedure-related complications (C). The primary outcome MACE was similar in the computed tomography (CT)–first and direct-to-invasive–coronary angiography (ICA) groups across all 3 age groups (age <65 years: 18 (1.5%) vs 28 (2.4%), hazard ratio [HR], 0.63; 95% CI, 0.35-.14; age between 65-75 years: 13 (2.6%) vs 19 (4.0%); HR, 0.64; 95% CI, 0.31-1.29; age >75 years: 7 (6.0%) vs 5 (4.9%); HR, 1.39; 95% CI, 0.44-4.41; P for interaction = .31). Shaded areas are the 95% CIs, and the dotted line represents the null effect.
See this image and copyright information in PMC

References

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