Coronary computed tomography angiography (CCTA)-guided management of patients with stable chest pain was associated with a sustained reduction of deaths related to coronary artery disease or non-fatal myocardial infarction (MI), long-term results of the SCOT-HEART trial have shown.
This is the headline 10-year finding of the study, an open-label, multicentre trial involving more than 4,000 patients treated at 12 outpatient cardiology chest pain clinics across Scotland, results of which were published in The Lancet authored by Michelle Williams (University of Edinburgh, Edinburgh, UK) alongside other SCOT-HEART investigators. During the trial, the study team assigned patients aged 18–75 years with symptoms of suspected stable angina 1:1 to undergo standard treatment either with or without the guidance of CCTA.
The study has previously shown that the use of CCTA led to a change in diagnosis in 27% of patients, a change in investigations in 15% of patients and a change in treatment in 23% of patients. At five years, this led to a reduction in the composite endpoint of coronary heart disease-related death or MI, with similar rates of coronary revascularisation and an increase in the use of preventive therapies when compared with standard care delivered without the aid of CCTA. The latest prespecified analysis sought to assess the impact of CCTA on the long-term management and outcomes for patients.
Enrolling from November 2010 to September 2014, SCOT-HEART recruited a total of 4,146 patients, who had a mean age of 57 years, half (2,073) of whom were assigned to standard care with CCTA and half (2,073) standard care without CCTA. After 10 years, the investigators report that coronary disease-related death or non-fatal MI were less frequent in the CCTA group (6.6%) vs. the standard care group (8.2%).
“In patients with stable chest pain, management guided by CCTA was associated with a sustained reduction in death from coronary heart disease or non-fatal myocardial infarction at 10 years, which appeared to be due to the prevention of non-fatal myocardial infarction,” the study’s authors write in their paper outlining the results in The Lancet. “These differences occurred despite no difference in the use of invasive coronary angiography or coronary revascularisation, although the use of preventive therapies remained higher in those with CCTA-guided management even after 10 years of follow-up.”
The findings could have important implications for the diagnosis and long-term prevention of coronary artery disease and MI, the study team suggests.
There are some limitations to the study, the authors acknowledge, including that outcomes and medication use were defined based on nationally coded data, and there was no independent clinical endpoint adjudication. Additionally, the investigators state that the diagnosis of coronary artery disease was higher in patients allocated to CCTA, which they suggest would be anticipated to lead to overestimation of coronary events in this group.
Alongside this, a small number of patients were lost to follow-up and subsequent crossover of clinical evaluations and investigations may have influenced patient management during the subsequent 10 years. Changing practice relating to the management of stable coronary disease and the evolution of CT technology and techniques may also have had a bearing over the length of the long-term follow-up, they note.
“We have shown that CCTA-guided management is associated with a beneficial long-term impact on patient care,” the SCOT-HEART investigators write in their concluding remarks. “After 10 years of follow-up, CCTA-guided management continued to be associated with reduction in the rates of coronary heart disease death or non-fatal myocardial infarction and sustained increases in the use of preventive therapies.”
