Randomised trial of stable chest pain investigation:3-year clinical and quality of life results from CE-MARC 2

Aims: Guidelines for suspected cardiac chest pain have used historical risk stratification tools, advocating invasive coronary angiography (ICA) first-line in those at highest risk. We aimed to determine whether different strategies to manage suspected stable angina affected medium-term cardiovascular event rates and patient-reported quality of life (QoL) measures. Methods: CE-MARC2, a three-arm parallel group trial, randomised patients with suspected stable cardiac chest pain and a Duke Clinical pre-test likelihood of coronary artery disease (CAD) between 10-90%. Patients were randomised to either first-line Cardiovascular Magnetic Resonance (CMR), single photon emission computed tomography (SPECT) or the UK NICE CG95(2010) guidelines-directed care. For the three arms, 1 and 3-year first-Major Adverse Cardiovascular Event (MACE) rates and QoL assessed by the Seattle Angina Questionnaire, SF12v2 and EQ-5D were recorded. Results: 1,202 patients were randomised to CMR (n=481), SPECT (n=481) and NICE (n=240). Forty-two patients (18 CMR, 18 SPECT, 6 NICE) experienced one or more MACE. The percentage rates (95% confidence intervals) of MACE in the CMR, SPECT and NICE groups at 3-years were 3.7% (2.4%, 5.8%), 3.7% (2.4%, 5.8%), 2.1% (0.9%, 4.8%) respectively. QoL scores did not significantly differ across domains. Conclusion: Despite a 4-fold increase in referrals for invasive coronary angiography, the NICE CG95 (2010) guidelines risk-stratified care strategy did not significantly reduce 3-year MACE or improve quality of life, as compared with functional imaging with CMR or SPECT.