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In this multicenter trial, 3561 patients with stable chest pain at intermediate risk for obstructive coronary artery disease were randomly assigned to undergo CT or invasive coronary angiography. Over 3.5 years of follow-up, there was no significant between-group difference in the risk of major adverse cardiovascular events. Major procedure-related complications were less common with CT.

In a randomized trial, patients with chest pain underwent a standard diagnostic evaluation with or without coronary CT angiography (CTA). The group assigned to CTA had a lower rate of death from coronary heart disease or nonfatal myocardial infarction at 5 years.

The Scottish Computed Tomography of the Heart (SCOT-HEART) trial demonstrated that management guided by coronary CT angiography (CCTA) improved the diagnosis, management, and outcome of patients with stable chest pain. We aimed to assess whether CCTA-guided care results in sustained long-term improvements in management and outcomes. SCOT-HEART was an open-label, multicentre, parallel group trial for which patients were recruited from 12 outpatient cardiology chest pain clinics across Scotland. Eligible patients were aged 18–75 years with symptoms of suspected stable angina due to coronary heart disease. Patients were randomly assigned (1:1) to standard of care plus CCTA or standard of care alone. In this prespecified 10-year analysis, prescribing data, coronary procedural interventions, and clinical outcomes were obtained through record linkage from national registries. The primary outcome was coronary heart disease death or non-fatal myocardial infarction on an intention-to-treat basis. This trial is registered at ClinicalTrials.gov (NCT01149590) and is complete. Between Nov 18, 2010, and Sept 24, 2014, 4146 patients were recruited (mean age 57 years [SD 10], 2325 [56·1%] male, 1821 [43·9%] female), with 2073 randomly assigned to standard care and CCTA and 2073 to standard care alone. After a median of 10·0 years (IQR 9·3–11·0), coronary heart disease death or non-fatal myocardial infarction was less frequent in the CCTA group compared with the standard care group (137 [6·6%] vs 171 [8·2%]; hazard ratio [HR] 0·79 [95% CI 0·63–0·99], p=0·044). Rates of all-cause, cardiovascular, and coronary heart disease death, and non-fatal stroke, were similar between the groups (p>0·05 for all), but non-fatal myocardial infarctions (90 [4·3%] vs 124 [6·0%]; HR 0·72 [0·55–0·94], p=0·017) and major adverse cardiovascular events (172 [8·3%] vs 214 [10·3%]; HR 0·80 [0·65–0·97], p=0·026) were less frequent in the CCTA group. Rates of coronary revascularisation procedures were similar (315 [15·2%] vs 318 [15·3%]; HR 1·00 [0·86–1·17], p=0·99) but preventive therapy prescribing remained more frequent in the CCTA group (831 [55·9%] of 1486 vs 728 [49·0%] of 1485 patients with available data; odds ratio 1·17 [95% CI 1·01–1·36], p=0·034). After 10 years, CCTA-guided management of patients with stable chest pain was associated with a sustained reduction in coronary heart disease death or non-fatal myocardial infarction. Identification of coronary atherosclerosis by CCTA improves long-term cardiovascular disease prevention in patients with stable chest pain. The Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Edinburgh and Lothian's Health Foundation Trust, British Heart Foundation, and Heart Diseases Research Fund.

Objective: Despite the availability of studies, there is a lack of available literature on the treatment of psychological and gastrointestinal causes of noncardiac chest pain (NCCP). Physiotherapeutic techniques involving diaphragmatic breathing, Jacobson’s relaxation and dynamic neuromuscular stabilization (DNS) could address these causes through the activation of parasympathetic system. Hence, this study aims to evaluate the combined effect of diaphragmatic breathing, Jacobson’s relaxation and DNS along with pharmacological therapy on patients with gastrointestinal and psychological causes of NCCP. Design: Randomized controlled trial. Setting: Cardiology OPD of a tertiary care hospital. Subjects: Eighty‐eight subjects with NCCP. Methods: The intervention group received diaphragmatic breathing, Jacobson’s relaxation technique, DNS and pharmacological treatment for 4 weeks. The control group was given pharmacological treatment with patient education. The Beck Depression Inventory (BDI) score, Hamilton Depression Rating Scale (HDRS) score, gastroesophageal reflux disease (GERD) questionnaire score and Numerical Pain Rating Scale (NPRS) score were measured at baseline and after 4 weeks of intervention. Results: The baseline characteristics and outcome measures were assessed, and no significant differences were noted in their mean values ( p > 0.05). After 4 weeks of intervention, a statistically significant difference was observed in BDI, HDRS, GERD questionnaire score and NPRS in both the groups ( p < 0.001). However, the GERD questionnaire and NPRS showed statistically significant decrease in the intervention group (GERD questionnaire: 28.39 ± 9.74 and NPRS: 4.57 ± 0.91) compared with the control group (GERD questionnaire: 35.54 ± 12.23 and NPRS: 4.95 ± 0.96) with p < 0.05. Conclusion: The diaphragmatic breathing exercises, Jacobson’s relaxation technique and DNS are beneficial for reducing GERD symptoms and pain in patients with NCCP. These techniques are safe and cost‐effective treatment for addressing the psychological and gastrointestinal causes of NCCP. These can be incorporated along with the pharmacological treatment to enhance the outcomes. However, future researches with long‐term follow‐ups are required. Trial Registration: Clinical Trials Registry ‐ India: CTRI/2025/02/081294

The optimal noninvasive diagnostic imaging strategy for patients with suspected coronary artery disease (CAD) is widely debated. Computed Tomography Coronary Angiography (CTCA) and functional imaging are both guideline-recommended, although comparative effectiveness in patients with intermediate-high pretest likelihood (PTL) is limited. Primary Hypothesis: We aim to establish if a personalized investigation strategy compared to CTCA first-line for allcomers, leads to improved patient outcomes. In a multi-center, randomized trial, 4,000 patients newly referred for the investigation of suspected cardiac chest pain will be recruited and randomized (1:1) to either personalized care (first-line CTCA or functional imaging based on PTL) or CTCA first-line for allcomers. The primary endpoint is time to a composite of cardiovascular death, myocardial infarction, or unobstructed coronary arteries on invasive angiography. Follow up will occur at 6 and 12 months and then annually for up to 4 years for symptoms, quality of life, and guideline directed medical therapy usage. A cost-effectiveness analysis will be performed capturing impacts on health, measured in quality adjusted life years (QALYs) using the EQ-5D-5L, and costs (including investigations, procedures, procedural complications, medical treatment costs and any future hospital admissions) calculated. It will be possible for the whole trial pathway to be conducted remotely with the option to perform non-face-to-face consent, randomization, and follow-up data collection including health-related quality of life. About 20 UK sites. First site opened April 2022 and recruitment is due to complete by July 2025, with an average recruitment of 135 patients a month to date. About 3,407 patients recruited and randomized by the end of February 2025 This trial will address whether, in patients with suspected cardiac chest pain, a strategy of personalized investigation according to pretest likelihood (PTL), compared to CTCA for allcomers, leads to improved patient outcomes, quality of life and cost-effectiveness.

Clinical work-up for suspected cardiac chest pain is resource intensive. Despite expectations, high-sensitivity cardiac troponin assays have not made decision making easier. The impact of recently validated rapid triage protocols including the 0-hour/1-hour hs-cTn protocols on care and outcomes may be limited by the heterogeneity in interpretation of troponin profiles by clinicians. We have developed machine learning (ML) models which digitally phenotype myocardial injury and infarction with a high predictive performance and provide accurate risk assessment among patients presenting to EDs with suspected cardiac symptoms. The use of these models may support clinical decision-making and allow the synthesis of an evidence base particularly in non-T1MI patients however prospective validation is required. We propose that integrating validated real-time artificial intelligence (AI) methods into clinical care may better support clinical decision-making and establish the foundation for a self-learning health system. This prospective, multicenter, open-label, cluster-randomized clinical trial within blinded endpoint adjudication across 12 hospitals (n = 20,000) will randomize sites to the clinical decision-support tool or continue current standard of care. The clinical decision support tool will utilize ML models to provide objective patient-specific diagnostic probabilities (ie, likelihood for Type 1 myocardial infarction [MI] versus Type 2 MI/Acute Myocardial Injury versus Chronic Myocardial Injury etc.) and prognostic assessments. The primary outcome is the composite of cardiovascular mortality, new or recurrent MI and unplanned hospital re-admission at 12 months post index presentation. Supporting clinicians with a decision support tool that utilizes AI has the potential to provide better diagnostic and prognostic assessment thereby improving clinical efficiency and establish a self-learning health system continually improving risk assessment, quality and safety. ANZCTR, Registration Number: ACTRN12620001319965, https://www.anzctr.org.au/.

The early and accurate diagnosis of acute myocardial infarction (AMI) is an important medical and economic challenge. We aimed to prospectively evaluate the performance of the new European Society of Cardiology rapid 0-hour/3-hour (0 h/3 h) rule out protocol for AMI. We enrolled 2,727 consecutive patients presenting with suspected AMI without persistent ST-segment elevation to the emergency department in a prospective international multicenter study. The final diagnosis was adjudicated by 2 independent cardiologists. The performance of the 0 h/3 h rule out protocol was evaluated using 4 high-sensitivity (primary analysis) and 3 sensitive cardiac troponin (cTn) assays. Acute myocardial infarction was the final diagnosis in 473 patients (17.3%). Using the 4 high-sensitivity cTn assays, the 0-hour rule out protocol correctly ruled out 99.8% (95% [confidence interval] CI, 98.7%-100%), 99.6% (95% CI, 98.5%-99.9%), 100% (95% CI, 97.9%-100%), and 100% (95% CI, 98.0%-100%) of late presenters (>6 h from chest pain onset). The 3-hour rule out protocol correctly ruled out 99.9% (95% CI, 99.1%-100%), 99.5% (95% CI, 98.3%-99.9%), 100% (95% CI, 98.1%-100%), and 100% (95% CI, 98.2%-100%) of early presenters (<6 h from chest pain onset). Using the 3 sensitive cTn assays, the 0-hour rule out protocol correctly ruled out 99.6% (95% CI, 98.6%-99.9%), 99.0% (95% CI, 96.9%-99.7%), and 99.1% (95% CI, 97.2%-99.8%) of late presenters; and the 3-hour rule out protocol correctly ruled out 99.4% (95% CI, 98.3%-99.8%), 99.2% (95% CI, 97.3%-99.8%), and 99.0% (95% CI, 97.2%-99.7%) of early presenters. Overall, the 0 h/3 h rule out protocol assigned 40% to 60% of patients to rule out. None of the patients assigned rule out died during 3-months follow-up. The 0 h/3 h rule out protocol seems to allow the accurate rule out of AMI using both high-sensitivity and sensitive cTn measurements in conjunction with clinical assessment. Additional studies are warranted for external validation.

AbstractObjectivesTo establish if the use of early computed tomography (CT) coronary angiography improves one year clinical outcomes in patients presenting to the emergency department with acute chest pain and at intermediate risk of acute coronary syndrome and subsequent clinical events.DesignRandomised controlled trial.Setting37 hospitals in the UK.ParticipantsAdults with suspected or a provisional diagnosis of acute coronary syndrome and one or more of previous coronary heart disease, raised levels of cardiac troponin, or abnormal electrocardiogram.InterventionsEarly CT coronary angiography and standard of care compared with standard of care only.Main outcome measuresPrimary endpoint was all cause death or subsequent type 1 or 4b myocardial infarction at one year.ResultsBetween 23 March 2015 and 27 June 2019, 1748 participants (mean age 62 years (standard deviation 13), 64% men, mean global registry of acute coronary events (GRACE) score 115 (standard deviation 35)) were randomised to receive early CT coronary angiography (n=877) or standard of care only (n=871). Median time from randomisation to CT coronary angiography was 4.2 (interquartile range 1.6-21.6) hours. The primary endpoint occurred in 51 (5.8%) participants randomised to CT coronary angiography and 53 (6.1%) participants who received standard of care only (adjusted hazard ratio 0.91 (95% confidence interval 0.62 to 1.35), P=0.65). Invasive coronary angiography was performed in 474 (54.0%) participants randomised to CT coronary angiography and 530 (60.8%) participants who received standard of care only (adjusted hazard ratio 0.81 (0.72 to 0.92), P=0.001). There were no overall differences in coronary revascularisation, use of drug treatment for acute coronary syndrome, or subsequent preventive treatments between the two groups. Early CT coronary angiography was associated with a slightly longer time in hospital (median increase 0.21 (95% confidence interval 0.05 to 0.40) days from a median hospital stay of 2.0 to 2.2 days).ConclusionsIn intermediate risk patients with acute chest pain and suspected acute coronary syndrome, early CT coronary angiography did not alter overall coronary therapeutic interventions or one year clinical outcomes, but reduced rates of invasive angiography while modestly increasing length of hospital stay. These findings do not support the routine use of early CT coronary angiography in intermediate risk patients with acute chest pain and suspected acute coronary syndrome.Trial registrationISRCTN19102565, NCT02284191.

Coronary CT angiography (CCTA) in the emergency department reduced the length of hospital stay and allowed more patients to be discharged directly from the emergency department. However, CCTA resulted in more downstream testing and higher exposure to radiation. Treatment of patients with acute chest pain but an inconclusive initial evaluation with the use of biomarkers and electrocardiographic (ECG) testing is often diagnostically challenging and inefficient. The majority of patients with acute coronary syndromes have underlying coronary artery disease. 1 Contrast-enhanced coronary computed tomographic angiography (CCTA) has high sensitivity and specificity for the detection of clinically significant coronary artery disease, as compared with invasive coronary angiography, in patients in stable condition with suspected or known coronary artery disease. 2 – 5 Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography (ROMICAT-I), 6 a blinded observational study involving patients in the emergency department with suspected . . .