Diseases of the heart and circulation are known as cardiovascular diseases, and they cause over 160,000 deaths each year.
Coronary heart disease (CHD) is the most common cardiovascular disease. This is due to a build-up of fatty material, known as atherosclerosis, in the blood vessels supplying blood to the heart muscle. This can cause chest pain or if blocked, can cause a heart attack.
Two of the main non-invasive tests to look for coronary heart disease are Computed Tomography Coronary Angiography (CTCA) and Stress Echocardiography (Ultrasound scan).
CTCA shows the arteries and allows small amounts of disease to be seen that may not yet be causing any symptoms. However, if there's lots of disease and calcification, it becomes difficult to tell how severe it is, which means several tests may be needed. Stress Echocardiography shows if enough blood is reaching the heart muscle, so can show if there is severe disease that needs treatment. However, it can't see the arteries so doesn't showt small disease that may benefit from tablet treatment. There is not yet an effective non-invasive combined test that can give all this information in one go.
Studies have shown that if there's atherosclerosis in another artery, a person is very likely to have coronary atherosclerosis as well. Carotid atherosclerosis, in the neck arteries, can be seen with ultrasound similar to stress echocardiography. So, by combining these two tests the investigators want to see if it is possible to see severe as well as small areas of disease in one test, to provide better treatment.
The study will enrol 2,000 participants, who need investigation for CHD, equally randomised to CTCA or stress echocardiography with carotid ultrasound. We will follow these participants for 5 years and observe for any adverse outcomes and ask them to complete a questionnaire.
Age > 18 years old
Patients referred to RACPC and judged by the reviewer to require a further imaging investigation, either SE or CTCA, to evaluate a suspected diagnosis of CAD
AND
Have a PTP score ≥ 5%, as calculated using ESC guidelines OR
Patients with diagnosed ACS that require urgent or emergency treatment or hospitalisation for inpatient investigations.
Known history of obstructive CAD (Previous MI, PCI or CABG) or previous invasive angiography with evidence of ≥ 50% stenosis in any epicardial vessel.
Patients who have undergone invasive or non-invasive, functional or anatomical (Including CAC score) testing for detection of CAD within the previous 1 year of clinical assessment.
Documented allergy to iodinated contrast or documented allergy to both ultrasound contrasts used at LNWH Trust; Luminity® (Perflutren) and SonoVue® (Sulphur Hexafluoride) or the constitutes
Parallel
Detection of obstructive coronary disease
Diagnostic testDetection of obstructive coronary disease
Detection of obstructive CAD and prevalence of MACE in enrolled participants
Assessment of resource utilisation between study arms (subsequent downstream testing, cardiac related hospital visits, costs and incremental cost effectiveness)
Assessment of overall ionising radiation exposure (dose) between study arms
Major complications from cardiovascular procedures or cardiovascular diagnostic testing
(a. Haemodynamically unstable new arrhythmia requiring emergency respiratory and/or circulatory support b. Anaphylaxis defined as a new severe reaction requiring emergency respiratory and/or circulatory support to administration of medication, including but not limited to; iodinated contrast, ultrasound contrast, dobutamine or atropine. c. Major bleeding requiring a transfusion of ≥ 1 unit of packed red blood cells and/or further interventional procedures related to bleeding management. d. Acute severe renal failure requiring ≥ 1 cycle of renal replacement therapy. e. Stroke defined as sudden onset focal neurological deficit with cerebral imaging confirming new stroke)
Analysis of patient derived chest pain related quality of life (EQ-5D)
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