{
  "abstract": "Background Patients with prior coronary artery bypass grafting (CABG) account for around 10% of non-ST-elevation acute coronary syndromes (NSTE-ACS), but the optimal diagnostic and management strategy remains uncertain. Invasive coronary angiography (ICA) in this group is technically challenging, carries increased risk and often does not lead to percutaneous coronary intervention (PCI). CT coronary angiography (CTCA) may help identify which patients benefit from ICA and reduce unnecessary invasive procedures.Methods In the BYPASS-CTCA (Randomised Controlled Trial to Assess Whether Computed Tomography Cardiac Angiography Can Improve Invasive Coronary Angiography in Bypass Surgery Patients) study, patients with prior CABG undergoing ICA were randomised to CTCA plus ICA or ICA alone. For this analysis, anonymised case vignettes and CTCA reports from 150 patients with NSTE-ACS were independently reviewed by 50 experienced interventional cardiologists (median 17 years post-qualification; 5103 total case reviews). Agreement on management strategy before and after CTCA was assessed using Fleiss’ κ statistic.Results Based on clinical information alone, respondents chose medical therapy in 13.2% of cases, with poor agreement on management strategy (κ=0.14, 95% CI 0.11 to 0.17). After reviewing CTCA, agreement improved to moderate (κ=0.53, 95% CI 0.48 to 0.58; p<0.001), and medical management was selected in 39.3% (p<0.001). When invasive management was selected post-CTCA, PCI was required in 85% of cases, and a selective angiographic approach was planned in 79%.Conclusions Management decisions for post-CABG NSTE-ACS vary widely among experienced cardiologists. Incorporating CTCA into the diagnostic pathway substantially improves consensus, reduces unnecessary invasive angiography and enables targeted, lower-risk procedures. These findings support evaluation of a CTCA-guided strategy in a prospective randomised trial.",
  "authors": [
    {
      "affiliations": [
        "Barts Heart Centre, Barts Health NHS Trust, London, UK",
        "Centre for Cardiovascular Medicine and Devices, Queen Mary University of London William Harvey Research Institute, London, UK",
        "NIHR Barts Biomedical Research Centre, Barts Heart Centre and William Harvey Research Institute, Queen Mary University of London, London, UK"
      ],
      "name": "Matthew Kelham"
    },
    {
      "affiliations": [
        "Barts Heart Centre, Barts Health NHS Trust, London, UK",
        "Centre for Cardiovascular Medicine and Devices, Queen Mary University of London William Harvey Research Institute, London, UK",
        "NIHR Barts Biomedical Research Centre, Barts Heart Centre and William Harvey Research Institute, Queen Mary University of London, London, UK"
      ],
      "name": "Anne-Marie Beirne"
    },
    {
      "affiliations": [
        "Barts Cardiovascular Clinical Trials Unit, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK"
      ],
      "name": "Annastazia E Learoyd"
    },
    {
      "affiliations": [
        "Barts Heart Centre, Barts Health NHS Trust, London, UK",
        "Centre for Cardiovascular Medicine and Devices, Queen Mary University of London William Harvey Research Institute, London, UK",
        "NIHR Barts Biomedical Research Centre, Barts Heart Centre and William Harvey Research Institute, Queen Mary University of London, London, UK"
      ],
      "name": "Krishnaraj S Rathod"
    },
    {
      "affiliations": [
        "Barts Heart Centre, Barts Health NHS Trust, London, UK"
      ],
      "name": "Fizzah Choudry"
    },
    {
      "affiliations": [
        "Barts Heart Centre, Barts Health NHS Trust, London, UK"
      ],
      "name": "Oliver Guttmann"
    },
    {
      "affiliations": [
        "Barts Heart Centre, Barts Health NHS Trust, London, UK"
      ],
      "name": "Ceri Davies"
    },
    {
      "affiliations": [
        "Barts Heart Centre, Barts Health NHS Trust, London, UK",
        "Centre for Cardiovascular Medicine and Devices, Queen Mary University of London William Harvey Research Institute, London, UK",
        "NIHR Barts Biomedical Research Centre, Barts Heart Centre and William Harvey Research Institute, Queen Mary University of London, London, UK"
      ],
      "name": "Francesca Pugliese"
    },
    {
      "affiliations": [
        "Department of Cardiovascular Sciences, University of Leicester and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK"
      ],
      "name": "Shazia T Hussain"
    },
    {
      "affiliations": [
        "Essex Cardiothoracic Centre, MSE, Basildon, UK",
        "MTRC, Anglia Ruskin University, Chelmsford, UK"
      ],
      "name": "Thomas Keeble"
    },
    {
      "affiliations": [
        "Cardiovascular Center OLV Aalst, Aalst, Belgium"
      ],
      "name": "Carlos Collet"
    },
    {
      "affiliations": [
        "City St George’s University of London, London, UK"
      ],
      "name": "James C Spratt"
    },
    {
      "affiliations": [
        "Department of Cardiology, University General Hospital of Patras, Patras, Greece"
      ],
      "name": "Grigorios Tsigkas"
    },
    {
      "affiliations": [
        "Barts Heart Centre, Barts Health NHS Trust, London, UK",
        "Centre for Cardiovascular Medicine and Devices, Queen Mary University of London William Harvey Research Institute, London, UK",
        "NIHR Barts Biomedical Research Centre, Barts Heart Centre and William Harvey Research Institute, Queen Mary University of London, London, UK",
        "Barts Cardiovascular Clinical Trials Unit, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK"
      ],
      "name": "Anthony Mathur"
    },
    {
      "affiliations": [
        "Barts Heart Centre, Barts Health NHS Trust, London, UK",
        "Centre for Cardiovascular Medicine and Devices, Queen Mary University of London William Harvey Research Institute, London, UK",
        "NIHR Barts Biomedical Research Centre, Barts Heart Centre and William Harvey Research Institute, Queen Mary University of London, London, UK",
        "Barts Cardiovascular Clinical Trials Unit, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK"
      ],
      "name": "Daniel A Jones"
    },
    {
      "affiliations": [],
      "name": "on behalf of the BYPASS-CTCA ACS collaborative"
    }
  ],
  "title": "Computed tomography coronary angiography to facilitate clinical decision-making and selective invasive angiography in patients with prior bypass grafting presenting with acute coronary syndromes",
  "uid": "ec053607-e046-572d-8cfb-4240e4c65603"
}