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Published on: April 25, 2014
Coronary CT Angiography and 5-Year Risk of Myocardial Infarction
, David E Newby1, Philip D Adamson1
1From the University of Edinburgh, Edinburgh (D.E.N., P.D.A., N.A.B., M.R.D., A.H., S.L., N.L.M., J.N., A.S.V.S., E.J.R.B., M.C.W.), the University of Glasgow, Glasgow (C.B., G.R.), the University of East Anglia, Norwich (M.F.), NHS Fife, Kirkcaldy (S.M.), and Queen Mary University, London (A.D.T.) - all in the United Kingdom; and the University of Limerick, Limerick, Ireland (J.F.).
Insights
Coronary computed tomographic angiography (CTA) significantly reduced 5-year risks of coronary heart disease death or heart attack in stable chest pain patients. This approach improved outcomes without increasing invasive procedures, enhancing patient care.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Clinical Trials
Background:
- Coronary computed tomographic angiography (CTA) enhances diagnostic certainty for stable chest pain.
- The long-term impact of CTA on 5-year clinical outcomes remained unknown prior to this study.
Purpose of the Study:
- To evaluate the effect of adding CTA to standard care on 5-year clinical outcomes in patients with stable chest pain.
Main Methods:
- An open-label, multicenter trial randomized 4146 patients with stable chest pain.
- Patients received either standard care plus CTA or standard care alone.
- The primary endpoint was death from coronary heart disease or nonfatal myocardial infarction at 5 years.
Main Results:
- The 5-year rate of the primary endpoint was significantly lower in the CTA group (2.3%) compared to the standard care group (3.9%).
- While initial rates of invasive coronary angiography and revascularization were higher in the CTA group, overall 5-year rates were similar between groups.
- Patients receiving CTA were more likely to be initiated on preventive and antianginal therapies.
Conclusions:
- Adding CTA to standard care significantly reduced the risk of coronary heart disease death or myocardial infarction at 5 years in stable chest pain patients.
- The benefits were achieved without a significant increase in invasive coronary angiography or coronary revascularization rates.
- CTA use led to increased initiation of preventive and antianginal therapies.
Background:
Although coronary computed tomographic angiography (CTA) improves diagnostic certainty in the assessment of patients with stable chest pain, its effect on 5-year clinical outcomes is unknown.
Methods:
In an open-label, multicenter, parallel-group trial, we randomly assigned 4146 patients with stable chest pain who had been referred to a cardiology clinic for evaluation to standard care plus CTA (2073 patients) or to standard care alone (2073 patients). Investigations, treatments, and clinical outcomes were assessed over 3 to 7 years of follow-up. The primary end point was death from coronary heart disease or nonfatal myocardial infarction at 5 years.
Results:
The median duration of follow-up was 4.8 years, which yielded 20,254 patient-years of follow-up. The 5-year rate of the primary end point was lower in the CTA group than in the standard-care group (2.3% [48 patients] vs. 3.9% [81 patients]; hazard ratio, 0.59; 95% confidence interval [CI], 0.41 to 0.84; P=0.004). Although the rates of invasive coronary angiography and coronary revascularization were higher in the CTA group than in the standard-care group in the first few months of follow-up, overall rates were similar at 5 years: invasive coronary angiography was performed in 491 patients in the CTA group and in 502 patients in the standard-care group (hazard ratio, 1.00; 95% CI, 0.88 to 1.13), and coronary revascularization was performed in 279 patients in the CTA group and in 267 in the standard-care group (hazard ratio, 1.07; 95% CI, 0.91 to 1.27). However, more preventive therapies were initiated in patients in the CTA group (odds ratio, 1.40; 95% CI, 1.19 to 1.65), as were more antianginal therapies (odds ratio, 1.27; 95% CI, 1.05 to 1.54). There were no significant between-group differences in the rates of cardiovascular or noncardiovascular deaths or deaths from any cause.
Conclusions:
In this trial, the use of CTA in addition to standard care in patients with stable chest pain resulted in a significantly lower rate of death from coronary heart disease or nonfatal myocardial infarction at 5 years than standard care alone, without resulting in a significantly higher rate of coronary angiography or coronary revascularization. (Funded by the Scottish Government Chief Scientist Office and others; SCOT-HEART ClinicalTrials.gov number, NCT01149590 .).
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