title: Effect of Care Guided by Cardiovascular Magnetic Resonance, Myocardial Perfusion Scintigraphy, or NICE Guidelines on Subsequent Unnecessary Angiography Rates: The CE-MARC 2 Randomized Clinical Trial.
abstract: Among patients with suspected coronary heart disease (CHD), rates of invasive angiography are considered too high.
  
  
  
  To test the hypothesis that among patients with suspected CHD, cardiovascular magnetic resonance (CMR)-guided care is superior to National Institute for Health and Care Excellence (NICE) guidelines-directed care and myocardial perfusion scintigraphy (MPS)-guided care in reducing unnecessary angiography.
  
  
  
  Multicenter, 3-parallel group, randomized clinical trial using a pragmatic comparative effectiveness design. From 6 UK hospitals, 1202 symptomatic patients with suspected CHD and a CHD pretest likelihood of 10% to 90% were recruited. First randomization was November 23, 2012; last 12-month follow-up was March 12, 2016.
  
  
  
  Patients were randomly assigned (240:481:481) to management according to UK NICE guidelines or to guided care based on the results of CMR or MPS testing.
  
  
  
  The primary end point was protocol-defined unnecessary coronary angiography (normal fractional flow reserve >0.8 or quantitative coronary angiography [QCA] showing no percentage diameter stenosis ≥70% in 1 view or ≥50% in 2 orthogonal views in all coronary vessels ≥2.5 mm diameter) within 12 months. Secondary end points included positive angiography, major adverse cardiovascular events (MACEs), and procedural complications.
  
  
  
  Among 1202 symptomatic patients (mean age, 56.3 years [SD, 9.0]; women, 564 [46.9%] ; mean CHD pretest likelihood, 49.5% [SD, 23.8%]), number of patients with invasive coronary angiography after 12 months was 102 in the NICE guidelines group (42.5% [95% CI, 36.2%-49.0%])], 85 in the CMR group (17.7% [95% CI, 14.4%-21.4%]); and 78 in the MPS group (16.2% [95% CI, 13.0%-19.8%]). Study-defined unnecessary angiography occurred in 69 (28.8%) in the NICE guidelines group, 36 (7.5%) in the CMR group, and 34 (7.1%) in the MPS group; adjusted odds ratio of unnecessary angiography: CMR group vs NICE guidelines group, 0.21 (95% CI, 0.12-0.34, P < .001); CMR group vs the MPS group, 1.27 (95% CI, 0.79-2.03, P = .32). Positive angiography proportions were 12.1% (95% CI, 8.2%-16.9%; 29/240 patients) for the NICE guidelines group, 9.8% (95% CI, 7.3%-12.8%; 47/481 patients) for the CMR group, and 8.7% (95% CI, 6.4%-11.6%; 42/481 patients) for the MPS group. A MACE was reported at a minimum of 12 months in 1.7% of patients in the NICE guidelines group, 2.5% in the CMR group, and 2.5% in the MPS group (adjusted hazard ratios: CMR group vs NICE guidelines group, 1.37 [95% CI, 0.52-3.57]; CMR group vs MPS group, 0.95 [95% CI, 0.46-1.95]).
  
  
  
  In patients with suspected angina, investigation by CMR resulted in a lower probability of unnecessary angiography within 12 months than NICE guideline-directed care, with no statistically significant difference between CMR and MPS strategies. There were no statistically significant differences in MACE rates.
  
  
  
  Clinicaltrials.gov Identifier: NCT01664858.
authors: Division of Biomedical Imaging, Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
authors: John P
authors: JP
authors: Greenwood
authors: Division of Biomedical Imaging, Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
authors: David P
authors: DP
authors: Ripley
authors: Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, United Kingdom.
authors: Colin
authors: C
authors: Berry
authors: Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom4NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, United Kingdom.
authors: Gerry P
authors: GP
authors: McCann
authors: Division of Biomedical Imaging, Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
authors: Sven
authors: S
authors: Plein
authors: Cardiovascular Magnetic Resonance Unit, National Institute for Health Research Bristol Cardiovascular Biomedical Research Unit, Bristol Heart Institute, University of Bristol, Bristol, United Kingdom.
authors: Chiara
authors: C
authors: Bucciarelli-Ducci
authors: Acute Vascular Imaging Centre, Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom.
authors: Erica
authors: E
authors: Dall'Armellina
authors: Cardiovascular Sciences Research Centre, St George's, University of London, London, United Kingdom.
authors: Abhiram
authors: A
authors: Prasad
authors: Division of Biomedical Imaging, Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
authors: Petra
authors: P
authors: Bijsterveld
authors: Division of Biomedical Imaging, Multidisciplinary Cardiovascular Research Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
authors: James R
authors: JR
authors: Foley
authors: Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, United Kingdom.
authors: Kenneth
authors: K
authors: Mangion
authors: Centre for Health Economics, University of York, York, United Kingdom.
authors: Mark
authors: M
authors: Sculpher
authors: Centre for Health Economics, University of York, York, United Kingdom.
authors: Simon
authors: S
authors: Walker
authors: Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom.
authors: Colin C
authors: CC
authors: Everett
authors: Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom.
authors: David A
authors: DA
authors: Cairns
authors: Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom.
authors: Linda D
authors: LD
authors: Sharples
authors: Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom.
authors: Julia M
authors: JM
authors: Brown
mesh_terms: D000368:Aged; D000787:Angina Pectoris / Q000000981:diagnostic imaging / Q000209:etiology; D017023:Coronary Angiography / Q000009:adverse effects; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging*; D023921:Coronary Stenosis / Q000000981:diagnostic imaging*; D003331:Coronary Vessels / Q000000981:diagnostic imaging; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D055414:Myocardial Perfusion Imaging / Q000009:adverse effects; D005791:Patient Care / Q000592:standards; D017410:Practice Guidelines as Topic; D019564:Unnecessary Procedures / Q000706:statistics & numerical data*