Dr. Baliga's 'Got Knowledge Doc?' PODKASTS

Coronary CT angiography-guided management of patients
with stable chest pain: 10-year outcomes from the SCOT-
HEART randomised controlled trial in Scotland

Michelle C Williams, Ryan Wereski, Christopher Tuck, Philip D Adamson, Anoop S V Shah, Edwin J R van Beek, Giles Roditi, Colin Berry,Nicholas Boon, Marcus Flather, Steff Lewis, John Norrie, Adam D Timmis, Nicholas L Mills, Marc R Dweck, David E Newby, on behalf of theSCOT-HEART Investigators*

Summary
Background The Scottish Computed Tomography of the Heart (SCOT-HEART) trial demonstrated that management
guided by coronary CT angiography (CCTA) improved the diagnosis, management, and outcome of patients with
stable chest pain. We aimed to assess whether CCTA-guided care results in sustained long-term improvements in
management and outcomes.

Methods SCOT-HEART was an open-label, multicentre, parallel group trial for which patients were recruited from
12 outpatient cardiology chest pain clinics across Scotland. Eligible patients were aged 18–75 years with symptoms of
suspected stable angina due to coronary heart disease. Patients were randomly assigned (1:1) to standard of care plus
CCTA or standard of care alone. In this prespecified 10-year analysis, prescribing data, coronary procedural
interventions, and clinical outcomes were obtained through record linkage from national registries. The primary
outcome was coronary heart disease death or non-fatal myocardial infarction on an intention-to-treat basis. This trial
is registered at ClinicalTrials.gov (NCT01149590) and is complete.

Findings Between Nov 18, 2010, and Sept 24, 2014, 4146 patients were recruited (mean age 57 years [SD 10], 2325 [56·1%] male, 1821 [43·9%] female), with 2073 randomly assigned to standard care and CCTA and 2073 to standard care
alone. After a median of 10·0 years (IQR 9·3–11·0), coronary heart disease death or non-fatal myocardial infarction
was less frequent in the CCTA group compared with the standard care group (137 [6·6%] vs 171 [8·2%]; hazard ratio
[HR] 0·79 [95% CI 0·63–0·99], p=0·044). Rates of all-cause, cardiovascular, and coronary heart disease death, and
non-fatal stroke, were similar between the groups (p>0·05 for all), but non-fatal myocardial infarctions (90 [4·3%] vs
124 [6·0%]; HR 0·72 [0·55–0·94], p=0·017) and major adverse cardiovascular events (172 [8·3%] vs 214 [10·3%];
HR 0·80 [0·65–0·97], p=0·026) were less frequent in the CCTA group. Rates of coronary revascularisation procedures
were similar (315 [15·2%] vs 318 [15·3%]; HR 1·00 [0·86–1·17], p=0·99) but preventive therapy prescribing remained
more frequent in the CCTA group (831 [55·9%] of 1486 vs 728 [49·0%] of 1485 patients with available data; odds ratio
1·17 [95% CI 1·01–1·36], p=0·034).

Interpretation After 10 years, CCTA-guided management of patients with stable chest pain was associated with a
sustained reduction in coronary heart disease death or non-fatal myocardial infarction. Identification of coronary
atherosclerosis by CCTA improves long-term cardiovascular disease prevention in patients with stable chest pain.