Loading...
In the SCOT-HEART randomized trial (NCT01149590), coronary computed tomographic angiography (CCTA) was shown to improve diagnostic certainty in patients with stable chest pain, but clinical outcomes at roughly 2 years were not clearly better than with exercise stress testing alone (NEJM JW Cardiol May 2015 and Lancet 2015: 385:2383). We now have a median of 4.8 years of follow-up from the 4146 trial participants.
At 5 years, the two groups did not differ significantly in all-cause or cardiovascular mortality. However, incidence of the primary endpoint — death from coronary heart disease or nonfatal myocardial infarction — was significantly lower with CCTA than with standard care alone (2.3% vs. 3.9%). Higher rates of invasive coronary angiography and coronary revascularization in the CCTA group during the first few months of follow-up became nonsignificant by 5 years. Overall, significantly more patients in the CCTA group than the standard care alone group initiated preventive therapies (19.4% vs. 14.7%) and antianginal therapies (13.2% vs. 10.7%).
The SCOT-HEART Investigators.Coronary CT angiography and 5-year risk of myocardial infarction. N Engl J Med 2018 Aug 25; [e-pub]. (https://doi.org/10.1056/NEJMoa1805971)
Hoffmann U and Udelson JE.Imaging coronary anatomy and reducing myocardial infarction. N Engl J Med 2018 Aug 25; [e-pub]. (https://doi.org/10.1056/NEJMe1809203)
Comment
In this trial, CCTA added to standard care was associated with lower mortality from coronary heart disease or nonfatal myocardial infarction than standard care alone, despite similar rates of coronary angiography or revascularization at 5 years, highlighting differences in medication prescription. The results suggest that CCTA-informed management of stable chest pain is associated with more-aggressive secondary prevention — and better outcomes — than management informed only by functional stress testing. The reasons for this finding are not entirely clear. Perhaps CCTA prompts clinicians to act upon discovering nonobstructive coronary heart disease that functional stress testing alone would not be likely to detect. It is not exactly clear how these data should be incorporated into clinical care, but they do highlight the importance of aggressive secondary prevention implementation for patients at risk.