Adding CCTA to chest pain assessment reduces likelihood of nonfatal MI (SCOT-HEART)

Reference

The 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.

Synopsis

These researchers identified Scottish adults with stable chest pain who had been referred to a cardiologist for evaluation. Patients with acute coronary syndrome in the past 3 months were excluded. All patients underwent the usual coronary evaluation, including an exercise stress test, and further evaluation as deemed appropriate by the treating cardiologist. They were then randomized to receive usual care plus CCTA or usual care alone. In the usual care group, physicians were asked to use a validated risk score to guide further management decisions, while physicians in the CCTA group were encouraged to use those results to guide care decisions. The decision to obtain an exercise stress test was up to the clinician, and was done for approximately 85% of patients in both groups. The numbers of cardiovascular events and deaths were obtained from a National Health Service registry, and, if necessary, confirmed by investigators masked to group assignment. A total of 4146 patients, with a mean age of 57 years, were randomized: 15% had an abnormal resting electrocardiogram, 35% had typical angina, 24% had atypical angina, a41% had nonanginal pain, and 9% had previous history of heart disease. Patients randomized to receive CCTA were no more likely to undergo angiography, percutaneous coronary intervention, or a coronary artery bypass graft than those in the comparison group. However, the CCTA group was less likely to experience the primary composite outcome of cardiovascular death or nonfatal myocardial infarction (2.3% vs 3.9%; P < .05; number needed to treat [NNT] = 63 over 5 years to prevent one death). The difference was primarily due to fewer nonfatal infarcts (2.1% vs 3.5%; NNT = 72), with no significant difference in cardiovascular deaths (0.2% vs 0.4%). There was no difference between groups in all-cause mortality. Subgroup analysis found no difference between groups based on age, sex, 10-year cardiovascular risk, diabetes, or type of chest pain.