Impact of smoking in patients with suspected coronary artery disease in the randomised DISCHARGE trial

Mancone, Massimo;Mézquita, Aldo J Vázquez;Birtolo, Lucia Ilaria;Maurovich-Horvat, Pal;Kofoed, Klaus F;Benedek, Theodora;Donnelly, Patrick;Rodriguez-Palomares, Jose;Erglis, Andrejs;Štěchovský, Cyril;Šakalytė, Gintare;Ađić, Nada Čemerlić;Gutberlet, Matthias;Diez, Ignacio;Davis, Gershan;Zimmermann, Elke;Kępka, Cezary;Vidakovic, Radosav;Francone, Marco;Ilnicka-Suckiel, Małgorzata;Plank, Fabian;Knuuti, Juhanni;Faria, Rita;Schröder, Stephen;Berry, Colin;Saba, Luca;Ruzsics, Balazs;Rieckmann, Nina;Kubiak, Christine;Hansen, Kristian Schultz;Müller-Nordhorn, Jaqueline;Merkely, Bela;Sigvardsen, Per E;Benedek, Imre;Orr, Clare;Valente, Filipa Xavier;Zvaigzne, Ligita;Suchánek, Vojtěch;Jankauskas, Antanas;Ađić, Filip;Woinke, Michael;Keane, Stephen;Lecumberri, Ignacio;Thwaite, Erica;Kruk, Mariusz;Jovanovic, Vladimir;Kuśmierz, Donata;Feuchtner, Gudren;Pietilä, Mikko;Ribeiro, Vasco Gama;Drosch, Tanja;Delles, Christian;Palmisano, Vitanio;Fisher, Michael;Drobni, Zsófia D;Kragelund, Charlotte;Aurelian, Rosca;Kelly, Stephanie;Del Blanco, Bruno Garcia;Rubio, Ainhoa;Boussoussou, Melinda;Hove, Jens D;Rodean, Ioana;Regan, Susan;Calabria, Hug Cuéllar;Becker, Dávid;Larsen, Linnea;Hodas, Roxana;Napp, Adriane E;Haase, Robert;Feger, Sarah;Mohamed, Mahmoud;Neumann, Konrad;Dreger, Henryk;Rief, Matthias;Wieske, Viktoria;Douglas, Pamela S;Estrella, Melanie;Bosserdt, Maria;Martus, Peter;Serna-Higuita, Lina M;Dodd, Jonathan D;Dewey, Marc

2023-01-01

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Abstract

Objectives: To investigate if the effect of cardiac computed tomography (CT) vs. invasive coronary angiography (ICA) on cardiovascular events differs based on smoking status. Materials and methods: This pre-specified subgroup analysis of the pragmatic, prospective, multicentre, randomised DISCHARGE trial (NCT02400229) involved 3561 patients with suspected coronary artery disease (CAD). The primary endpoint was major adverse cardiovascular events (MACE: cardiovascular death, non-fatal myocardial infarction, or stroke). Secondary endpoints included an expanded MACE composite (MACE, transient ischaemic attack, or major procedure-related complications). Results: Of 3445 randomised patients with smoking data (mean age 59.1 years + / - 9.7, 1151 men), at 3.5-year follow-up, the effect of CT vs. ICA on MACE was consistent across smoking groups (p for interaction = 0.98). The percutaneous coronary intervention rate was significantly lower with a CT-first strategy in smokers and former smokers (p = 0.01 for both). A CT-first strategy reduced the hazard of major procedure-related complications (HR: 0.21, 95% CI: 0.03, 0.81; p = 0.045) across smoking groups. In current smokers, the expanded MACE composite was lower in the CT- compared to the ICA-first strategy (2.3% (8) vs 6.0% (18), HR: 0.38; 95% CI: 0.17, 0.88). The rate of non-obstructive CAD was significantly higher in all three smoking groups in the CT-first strategy. Conclusion: For patients with stable chest pain referred for ICA, the clinical outcomes of CT were consistent across smoking status. The CT-first approach led to a higher detection rate of non-obstructive CAD and fewer major procedure-related complications in smokers. Clinical relevance statement: This pre-specified sub-analysis of the DISCHARGE trial confirms that a CT-first strategy in patients with stable chest pain referred for invasive coronary angiography with an intermediate pre-test probability of coronary artery disease is as effective as and safer than invasive coronary angiography, irrespective of smoking status. Trial registration: ClinicalTrials.gov NCT02400229. Key points: • No randomised studies have assessed smoking status on CT effectiveness in symptomatic patients referred for invasive coronary angiography. • A CT-first strategy results in comparable adverse events, fewer complications, and increased coronary artery disease detection, irrespective of smoking status. • A CT-first strategy is safe and effective for stable chest pain patients with intermediate pre-test probability for CAD, including never smokers.