Assessment of Patients With Suspected Coronary Artery Disease (CAD): What is the Best Initial Imaging Strategy? (IMAGE-CAD)

Assessment of Patients With Suspected CAD: What is the Best Initial Imaging Strategy? Cardiac Computed Tomographic Angiography,(CCTA) vs Stress Echocardiography (SE) vs SPECT

Patients who present with chest pain are investigated with tests designed to confirm or exclude the presence of Coronary Artery Disease (CAD), as well as determine risk of poor outcome. It is not known which imaging test would be best when used first for investigating a patient presenting with exertional chest pain. This trial is designed to compare outcomes of the use of coronary CT, stress echocardiography and nuclear perfusion (SPECT) in a pilot study. Patients with no history of coronary disease presenting with chest pain will be randomly assigned to one of the three test modalities as the initial imaging test. The three imaging strategies will be compared regarding the subsequent use of healthcare resources over a year.

Study Overview

• Status: Completed
• Conditions: Coronary Artery Disease

Detailed Description

This is a pilot study on imaging strategies for diagnosis of coronary artery disease. The pilot trial aims to answer the question "Which non-invasive test (single photon emission computed tomography (SPECT), stress echocardiography or coronary CT angiography (CCTA)) is the best first test in suspected coronary artery disease with respect to patient outcome and downstream health costs?" Patients are randomly assigned to one of the imaging modalities. All imaging and therapeutic procedures in this trial are clinically indicated. The only change from standard patient management is the selection of the initial imaging test. Instead of leaving the selection of the initial imaging test to the referring physician (whose decision is not evidence based), patients presenting with chest pain that fall into the inclusion/exclusion criteria of the study will be randomly assigned to one of the imaging modalities. Patients will also be followed at 1, 6 and 12 months after enrolment to determine outcomes. The three imaging strategies will be compared regarding subsequent use of healthcare resources over a year. In most large cardiac centres, different imaging modalities are performed by different specialists and therefore an operating grant from one imaging specialty rarely covers the costs of other imaging specialties in comparative studies. To ensure a fair comparison between modalities, all modalities have to be equal. Previous comparative trials have been criticized for being biased towards the technique being promoted by the principal investigator. This trial is unique in that the directors of nuclear cardiology, coronary computed tomography and echocardiography are all specialists in their field and are running state-of-the-art services and were all involved in the early planning of this trial and their involvement has ensured trial design meets clinical need. The results of this trial will give insight into planning of a larger multicentre, multi-national study.

• Study Type: Observational
• Enrollment (Actual): 173

Contacts and Locations

Study Locations

• Canada
  • Alberta
    • Edmonton, Alberta, Canada, T6G2B7
      • Mazankowski Alberta Heart Institute

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Probability Sample

Study Population

Men and women without known CAD who present with symptoms suggestive of CAD and require diagnostic/prognostic workup.

Description

Inclusion Criteria:

• Adult Age ≥ 18 years
• Presenting with symptoms suggestive of CAD requiring diagnostic/prognostic workup
• Suitable for Contrast Stress Echocardiography, SPECT and CCTA
• Able and willing to provide consent

Exclusion Criteria:

• Patients with documented CAD (previous invasive angiography, previous STEMI, previous PCI or CABG)
• NSTEMI, ACS within 3 months
• Previous diagnostic imaging tests in the past 6 months
• Women who are pregnant as evidenced by positive pregnancy test
• Breast feeding females
• Significant valvular heart disease (i.e. severe aortic stenosis or regurgitation or severe mitral regurgitation)
• Hemodynamic instability (blood pressure >210/110 ml/Hg or <90/60 mm/Hg)
• Unavailability for follow-up
• Renal insufficiency, eGFR < 30 ml/minute unless on dialysis
• Known allergy to x-ray or echo contrast agents
• Weight exceeding specifications of nuclear equipment (>250 Kg)
• Unable to give informed consent

Study Plan

How is the study designed?

Number of groups / cohorts

3

Cohorts and Interventions

Group / Cohort
Stress Echocardiography; Patients will be randomized to one of three imaging modalities. One imaging modality thay can be randomized to is Stress Echocardiography.
SPECT; Patients will be randomized to one of three imaging modalities. One imaging modality thay can be randomized to is Single Photon Emission Computed Tomography (SPECT)
CCTA; Patients will be randomized to one of three imaging modalities. One imaging modality thay can be randomized to is Cardiac Computed Tomographic Angiography (CCTA)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
healthcare resource utilization	12 month

Secondary Outcome Measures

Outcome Measure	Time Frame
referral rates to coronary angiography following three different initial imaging tests in this patient population.	12 month
coronary lesions which warrant revascularization (including those where it was warranted but not technically possible).	12 month
radiation exposure from the initial and subsequent imaging procedures	12 month
total mortality	12 month
freedom from angina	12 month
non-fatal myocardial infarction	12 month
hospital admissions for angina	12 month

Collaborators and Investigators

• Sponsor: Harald Becher
• Collaborators: Alberta Health services; University of Alberta
• Investigators: Principal Investigator: Harald Becher, MD,PhD,FRCP, University of Alberta, Alberta Health Services

Study record dates

Study Major Dates

• Study Start: July 1, 2012
• Primary Completion (Actual): January 1, 2017
• Study Completion (Actual): January 1, 2017

Study Registration Dates

• First Submitted: August 13, 2012
• First Submitted That Met QC Criteria: August 14, 2012
• First Posted (Estimate): August 20, 2012

Study Record Updates

• Last Update Posted (Actual): March 16, 2017
• Last Update Submitted That Met QC Criteria: March 15, 2017
• Last Verified: March 1, 2017

More Information

Terms related to this study

• Keywords: Coronary Artery Disease; outcomes; Stress Echocardiography; Single Photon Emission Computed Tomography; Cardiac Computed Tomographic Angiography
• Additional Relevant MeSH Terms: Heart Diseases; Cardiovascular Diseases; Vascular Diseases; Arteriosclerosis; Arterial Occlusive Diseases; Coronary Artery Disease; Myocardial Ischemia; Coronary Disease
• Other Study ID Numbers: CMI 1D; Pro00026591 (Other Identifier: Health Research Ethics Board)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO