Coronary CTA Superior to Standard Care in Stable Chest Pain

Coronary computed tomographic angiography (CTA) was associated with a lower 5-year mortality rate from coronary heart disease (CHD) or nonfatal myocardial infarction in patients with stable chest pain compared with standard care alone, according to the results of a study presented at the European Society of Cardiology Congress in Munich, Germany, and simultaneously published in the New England Journal of Medicine.

These benefits were observed without the need for greater coronary angiography or coronary revascularization procedures.

A total of 4146 patients with stable chest pain who were referred to an outpatient cardiology clinic were enrolled in the Scottish Computed Tomography of the Heart Trial (SCOT-HEART; ClinicalTrials.gov Identifier: NCT01149590). Investigators randomly assigned patients to either standard care plus CTA (n=2073) or standard care alone (n=2073). Clinical outcomes were assessed during 3 to 7 years of therapy.

Mortality from CHD or nonfatal myocardial infarction at 5 years comprised the primary end point. In addition, the investigators evaluated rates of invasive coronary angiography and coronary revascularization (eg, percutaneous coronary intervention and coronary artery bypass grafting) at follow-up.

During the median follow-up of 4.8 years, the rate of the primary end point was significantly lower in patients assigned to CTA plus standard care vs standard care only (2.3% vs 3.9%, respectively; hazard ratio [HR], 0.59; 95% CI, 0.41-0.84; P =.004).

At the average 5-year follow-up, the number of patients undergoing invasive coronary angiography was similar between patients receiving CTA and standard care (491 patients vs 502 patients, respectively; HR, 1.00; 95% CI, 0.88-1.13). Coronary revascularization rates were also similar between the CTA and standard care groups (279 patients vs 267 patients, respectively; HR, 1.07; 95% CI, 0.91-1.27).

A greater number of preventative therapies were administered in patients randomly assigned to CTA vs standard care (odds ratio [OR], 1.40; 95% CI, 1.19-1.65). Also, a significantly higher number of antianginal therapies were initiated in the CTA group (OR, 1.27; 95% CI, 1.05-1.54). No differences were found between the groups with regard to the rates of cardiovascular deaths (HR, 0.43; 95% CI, 0.15-1.22), noncardiovascular deaths (HR, 1.24; 95% CI, 0.77-2.00), or deaths from any cause (HR, 1.02; 95% CI, 0.67-1.55).

Limitations of the analysis included its open-label design and the lack of data on patients’ lifestyle changes during follow-up.

The investigators did find higher rates of invasive angiography and coronary revascularization in the standard care group beyond 1 year, which appears to be “consistent with both the emergence of unrecognized disease and nonfatal myocardial infarction in the standard-care group and the reduction in disease progression in the CTA group owing to the implementation of lifestyle modifications and preventive therapies.”

Reference

SCOT-HEART Investigators, Newby DE, Adamson PD, et al. Coronary CT angiography and 5-year risk of myocardial infarction. N Engl J Med. 2018;379(10):924-933.