Addition of CT angiography to standard care for stable chest pain reduces mortality due to coronary disease

1. Patients with stable chest pain referred to a cardiology clinic who received standard care plus coronary CT angiography (CTA) experienced lower 5-year rate of death due to coronary disease compared to those receiving standard care alone.

2. Patients in the CTA group received more preventative and antianginal therapies compared to the standard care group. Both groups had similar rates of coronary revascularization and invasive coronary angiography procedures.

Evidence Rating Level: 1 (Excellent)     

Study Rundown: Multiple clinical modalities are available to evaluate cardiac function and structure of patients with stable chest pain. Coronary CTA is often used for evaluation of stable chest pain as it is helpful for diagnosing various conditions, but how its use is ultimately related to prevention of death due to heart disease is presently unknown. This randomized parallel-group control trial sought to evaluate 5-year clinical outcomes in patients receiving standard cardiology care for stable chest pain, though one group received an initial coronary CTA. The primary outcome of death from coronary disease of nonfatal myocardial ischemia at 5-years was significantly lower in the group receiving a coronary CTA versus the standard care group. Rates of invasive coronary procedures were similar between the two groups at 5 years, though the CTA group received more preventative and antianginal therapy compared to the standard care group.

Strengths of this study include its randomized design, relatively long-term follow-up, and evaluation of associated therapies or procedures. Limitations include the open-label trial design and the limited number of secondary endpoints.

Click to read the study in NEJM

Relevant Reading: Safety of coronary CT angiography and functional testing for stable chest pain in the PROMISE trial: A randomized comparison of test complications, incidental findings, and radiation dose

In-Depth [randomized controlled trial]: This randomized parallel-group SCOT-HEART (Scottish Computed Tomography of the Heart) trial enrolled patients between 2010 and 2014. Eligible adult patients were referred to a cardiology clinic for stable chest pain. Patients were randomized in a 1:1 manner to received standard care (n=2073) or standard care plus a coronary CTA (n=2073). Patients were not routinely followed-up per the study protocol, as outcomes were assessed using a national health record. The primary outcome was a composite of death due to coronary disease of nonfatal myocardial infarction. Other endpoints included death due to any cause, cardiovascular death, and stroke. Health records were used to assess patients receiving coronary procedures or other therapies. Patients assigned to the CTA group were more likely to receive preventative therapies than those in the standard care group (19.4% vs 14.7%; odds ratio [OR], 1.40; 95% confidence interval [CI]m 1.19 to 1.65) as well as antianginal therapies (13.2% vs 10.7%; OR, 1.27; 95% CI, 1.05 to 1.54). No difference was detected between groups at 5 years for rates of invasive coronary angiography or coronary revascularization. The primary end-point was lower in the CTA group compared to the standard care group (2.3% vs 3.9%; hazard ratio [HR], 0.59; 95% CI, 0.41 to 0.84; P=0.004). The primary end-point differences between groups was similar when subgroups and individual treatment centers were analyzed.

Image: PD

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