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SCOT-HEART: CTA with standard care reduces CHD death, MI at 5 years
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MUNICH — Patients with stable chest pain who underwent CTA with standard care had a significantly lower rate of CHD-related death and nonfatal MI at 5 years compared with standard care alone, according to new data from the SCOT-HEART trial presented at the European Society of Cardiology Congress.
Long-term results from this trial have also been published in The New England Journal of Medicine.
As Cardiology Today previously reported, the SCOT-HEART trial found that 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.
A routine clinical evaluation was performed on all patients to collect information on diagnosis, symptoms, treatment strategy and further investigations such as invasive coronary angiography or stress imaging. Patients were then assigned either standard care with CTA (n = 2,073) or standard care alone (n = 2,073).
Condition management was at the discretion of the attending clinician throughout the trial. Physicians who cared for patients assigned CTA were to consider CTA results for management decisions, whereas physicians for patients assigned standard care alone were to consider the ASSIGN score for management decisions.
The clinical endpoint of interest were death, stroke and MI. The primary endpoint was nonfatal MI or death from CHD. The prespecified long-term endpoint was the number of patients who died from CHD or had a nonfatal MI at 5 years. Patients were followed up for a median of 4.8 years, which resulted in 20,254 patient-years of follow-up.
The primary long-term endpoint occurred less often in the CTA group vs. the standard care group (2.3% vs. 3.9%; HR = 0.59; 95% CI, 0.41-0.84).
In the first few months of follow-up, there was a higher rate of early coronary revascularization in patients assigned CTA compared with standard care. There was no difference between the two groups at 5 years. Invasive coronary angiography was performed in 23.6% of patients in the CTA group vs. 24.2% in the standard care group (HR = 1; 95% CI, 0.88-1.13). Coronary revascularization was performed in 12.9% of patients assigned standard care alone compared with 13.5% in patients assigned CTA and standard care (HR = 1.07; 95% CI, 0.91-1.27).
Patients in the CTA group were more likely to have received preventive therapies compared with those in the standard care group (19.4% vs. 14.7% OR = 1.4; 95% CI, 1.19-1.65). This was also seen regarding antianginal therapies (13.2% vs. 10.7%; OR = 1.27; 95% CI, 1.05-1.54).
“What we have shown after 5 years of follow-up is that CT angiography-guided management halved the rate of fatal and nonfatal myocardial infarction,” Newby said during a presentation. “Revascularization procedures are equal across the treatment groups, because early revascularization increases are offset by later decreases with CT guidance. This does beg the question as to whether CT angiography now should be viewed as the test of choice in patients with stable chest pain.”
The rates of CV and non-CV deaths or deaths from any cause did not have significant between-group differences.
“Overall, all patients appeared to derive similar benefits from CTA, which raises the question of whether more widespread testing may be helpful, irrespective of symptoms,” Newby and colleagues wrote. “Our data suggest that 63 patients with stable chest pain would need to be referred for CTA to prevent one fatal or nonfatal myocardial infarction over the course of 5 years.” – by Darlene Dobkowski
References:
Newby DE, et al. N Engl J Med. 2018;doi:10.1056/NEJMoa1805971.
Disclosures: Newby reports he received grants from Siemens. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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Kim Allan Williams Sr., MD, MACC, FAHA, MASNC
CTA is still a test that is underutilized. A lot of that had to do with the fact that other studies have shown that it increases utilization of downstream testing, particularly invasive coronary angiography, maybe without adding value to the patient.
Therefore, this is a landmark study. It is really about making sure we no longer have this paradigm in cardiology where we are mopping up the floor instead of turning off the faucet. Since this is not active prevention, it is not turning off the faucet. It is preventing our reacting so late that that the damage has already been done. It is more like taking a bucket and putting it under the sink so the floor does not get wet. We are making an earlier diagnosis that allows us to prevent some of the events after a diagnosis. This is a tremendous improvement in our armamentarium.
Now the trick is to get it applied in clinical practice. Payers will still be reluctant to pay. We need to increase our advocacy so patients have this test available to them frequently. The radiation is incredibly small now as long as we are using modern techniques.
So, we have a test that has a real big impact, because physicians’ response to it has a major clinical impact.
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