Coronary calcium scoring in the evaluation of stable chest pain in general practice: a cluster-randomised trial.

IF 4.4 2区医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS

Heart Pub Date : 2026-08-17 DOI:10.1136/heartjnl-2025-327687

Moniek Y Koopman, Thom E J Severijn, Jorn J W Reijnders, Grigory Sidorenkov, Marcel Van Tuinen, Carine J M Doggen, Geert Jan Dinant, Mathijs O Versteylen, Jan-Willem C Gratama, Richard Braam, Bastiaan Kietselaer, Rykel Van Bruggen, Robert Willemsen, Pim van der Harst, Rozemarijn Vliegenthart

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引用次数: 0

Abstract

Background: General practitioners (GPs) have limited tools for chest pain patients to identify (non-)obstructive coronary artery disease (OCAD). This trial evaluates whether GP access to the coronary artery calcium score (CACS) improves diagnostic efficiency and cardiovascular risk management (CVRM).

Methods: COroNary Calcium scoring as fiRst-linE Test to dEtect and exclude coronary artery disease in GP patients with stable chest pain (CONCRETE) is a pragmatic, non-blinded implementation study that cluster-randomised 101 Dutch GP offices into CACS or standard of care (SOC). Patients aged ≥40 (men) or ≥45 (women) years, without known CAD, with possible cardiac or non-cardiac chest pain were included. The primary outcome was the proportional 2-year increase in CVRM registrations at GP office level. Patient-level secondary outcomes included cardiologist referral rate, OCAD diagnosis and CVRM enrolment.

Results: At GP office level, no significant difference in CVRM registration increase was seen for CACS versus SOC (46 CACS practices: +0.3%, 45 SOC practices: +0.2%, p=0.77). Per protocol analysis for patient-level outcomes included 583 patients (57.5% women, mean age 60.6±9.1 years) (CACS arm: 466; SOC arm: 117), recruited between January 2019 and October 2023. The CACS arm showed 47.1% relative reduction in cardiologist referrals compared with SOC (42.5% vs 80.3%; modelled difference 31.3% (95% CI 14.8% to 47.8%)). OCAD detection rates were not significantly different (CACS: 4.9, SOC: 7.7%, p=0.14). Patients with higher CACS had a higher probability of cardiologist referral (from 8.4% for CACS 0 to 94.2% for CACS ≥400, difference +85.7% (95% CI 79.4% to 91.9%)) and of OCAD diagnosis (0% for CACS 0 to 21.2% for CACS ≥400, OR 9.08 (95% CI 4.20 to 19.67)). Compared with SOC, more CACS patients were enrolled in CVRM (36.3% vs 17.0%, p<0.01).

Conclusions: In this pragmatic, primary-care implementation and proof-of-concept trial, CACS was an effective diagnostic test for stable chest pain patients with (very) low likelihood of OCAD. CACS reduced unnecessary cardiology referrals and enhanced individual preventive care, without demonstrable practice-level impact on CVRM registrations.

Registration: The CONCRETE study is registered under CCMO Register NL66821.042.18 and closed for enrolment.

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冠状动脉钙评分在一般实践中评估稳定性胸痛：一项随机分组试验。

背景：全科医生（gp）对胸痛患者识别（非）阻塞性冠状动脉疾病（OCAD）的工具有限。本试验评估GP获取冠状动脉钙评分（CACS）是否能提高诊断效率和心血管风险管理（CVRM）。方法：冠状动脉钙评分作为检测和排除稳定胸痛（CONCRETE） GP患者冠状动脉疾病的一线测试是一项实用的非盲性实施研究，该研究将101个荷兰GP办公室随机分组到CACS或标准护理（SOC）中。患者年龄≥40岁（男性）或≥45岁（女性），无已知CAD，可能有心源性或非心源性胸痛。主要结果是GP级别的crvrm注册数按比例增加2年。患者水平的次要结局包括心脏病专家转诊率、OCAD诊断和CVRM登记。结果：在GP办公室水平上，CACS与SOC的CVRM注册增加无显著差异（46个CACS实践：+0.3%，45个SOC实践：+0.2%,p=0.77）。每个方案分析的患者水平结果包括583例患者（57.5%为女性，平均年龄60.6±9.1岁）（CACS组：466例；SOC组：117例），于2019年1月至2023年10月招募。与SOC组相比，CACS组的心脏病专家转诊相对减少47.1% （42.5% vs 80.3%；模型差异31.3% (95% CI 14.8%至47.8%)）。OCAD检出率差异无统计学意义（CACS: 4.9, SOC: 7.7%, p=0.14）。CACS较高的患者有更高的转诊概率（从CACS 0的8.4%到CACS≥400的94.2%，差异+85.7% (95% CI 79.4%至91.9%)）和OCAD诊断（CACS 0的0%到CACS≥400的21.2%,OR 9.08 (95% CI 4.20至19.67)）。与SOC相比，更多的CACS患者入组CVRM （36.3% vs 17.0%）。结论：在这项实用的初级保健实施和概念验证试验中，CACS是一种有效的诊断方法，用于（非常）低可能性的OCAD的稳定胸痛患者。CACS减少了不必要的心脏病转诊，加强了个人预防护理，对crvrm注册没有明显的实践水平影响。注册：CONCRETE研究在CCMO注册号NL66821.042.18下注册，并已结束注册。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Heart 医学-心血管系统

CiteScore

10.30

自引率

5.30%

发文量

320

审稿时长

3-6 weeks

期刊介绍： Heart is an international peer reviewed journal that keeps cardiologists up to date with important research advances in cardiovascular disease. New scientific developments are highlighted in editorials and put in context with concise review articles. There is one free Editor’s Choice article in each issue, with open access options available to authors for all articles. Education in Heart articles provide a comprehensive, continuously updated, cardiology curriculum.