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SCOT-HEART: CTCA may reduce future MI risk in patients with suspected angina
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SAN DIEGO — Among patients presenting with suspected angina due to CHD, use of CT coronary angiography aided physicians in clarifying diagnoses, enabled targeting of interventions and was associated with a trend toward lower MI compared with standard care.
The prospective, open-label, parallel-group study included patients referred for suspected angina due to CHD from 12 centers in Scotland from November 2010 to September 2014. The final analysis included 4,146 patients who were randomly assigned standard care plus CT coronary angiography (CTCA) or standard care alone.
The primary endpoint was a diagnosis of angina secondary to CHD at 6 weeks.
Baseline data indicated that 47% of patients had a clinical diagnosis of CHD, and 36% had a diagnosis of angina due to CHD.
Six-week results demonstrated that CTCA reclassified the diagnosis of CHD in 27% of patients and the diagnosis of angina due to CHD in 23% of patients, compared with 1% of patients in the standard-care group (P < .0001).
Researchers reported that the certainty (RR = 2.56; 95% CI, 2.332.79) and frequency of CHD increased (RR = 1.09; 95% CI, 1.02-1.17). For the diagnosis of angina due to CHD, the certainty increased (RR = 1.79; 95% CI, 1.62-1.96) and the frequency decreased (RR = 0.93; 95% CI, 0.85-1.02).
This was associated with changed planned investigations (15% vs. 1%) and treatments (23% vs. 5%; P < .0001 for both), but not associated with symptom severity at 6 weeks or readmissions for chest pain.
CTCA was associated with a 38% reduction in hard clinical outcomes including fatal and nonfatal MI after 1.7 years (HR = 0.62; 95% CI, 0.38-1.01; P = .0527).
David E. Newby, MD, from the University of Edinburgh and the NHS Lothian Health Board, United Kingdom, said this is the first trial to assess the clinical impact of the addition of CTCA in patients presenting with suspected angina due to CHD in the cardiology clinic.
“The testing is taking the guessing out of diagnosing people with coronary heart disease,” Newby said. – by Rob Volansky
References:
Newby DE, et al. Joint Session of the ACC/JAMA Late-Breaking Clinical Trials. Presented at: American College of Cardiology Scientific Sessions; March 14-16, 2015; San Diego.
The SCOT-HEART investigators. Lancet. 2015;doi:10.1016/S0140-6736(15)60291-4.
Disclosure: Newby reports associations with AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim, Eli-Lilly, GlaxoSmithKline, MSD, Pfizer, Roche and Toshiba.
Perspective
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David E. Winchester, MD, MS, FACC, FACP*
The SCOT-HEART trial demonstrates that by directly visualizing the coronaries, clinicians are more certain of the diagnosis of angina. Those without CAD could also be more confidently diagnosed, resulting in an apparent decrease in the frequency of CAD/angina diagnosis for the CT group. Patients with nonobstructive CAD can be accurately treated with medical therapy, which was more common in the CT group.
Clinicians with access to cardiac CT should consider it for their patients with chest pain. The certainty of diagnosis is greater with CT than functional testing, leading to more patients being on preventive medical therapy and those without CAD being directed towards testing for other conditions.
As with other trials, cardiac CT appeared to increase the use of invasive angiography and revascularization. In contrast with other trials, CT was also associated with a reduction in cardiac events. Neither were significant and event rates were overall low, so these findings must be interpreted cautiously.
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