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Effect of Coronary CT Angiography on Outcomes
Study Questions:
What are the patterns of treatment changes and consistency of reduced adverse events in patients with stable chest pain undergoing coronary computed tomography angiography (CTA)?
Methods:
From the open-label SCOT-HEART trial of 4,146 individuals with stable chest pain randomized to usual care or coronary CTA with usual care, the rate of adverse events (death from coronary heart disease [CHD] or nonfatal myocardial infarction) was examined in subgroups stratified by symptoms, diagnosis, revascularization, and medical therapy.
Results:
Subjects randomized to coronary CTA had lower rates of adverse events whether they had nonanginal chest pain, possible angina, or prior CHD. In patients where the final diagnosis was negative for angina due to CHD, CTA was associated with reduced adverse events (rate 0.23, p < 0.001). Following testing, 6% in the usual care arm had antiplatelet and/or statin medication changes, while 23% in the CTA arm had medication changes. While there were no differences in medications at baseline between groups, the CTA group had significantly increased use of both antiplatelet therapy and statins on follow-up at each year up to 5 years (p < 0.001 for each). The largest increases in medication changes were noted in patients with nonanginal chest pain and possible angina. In the CTA arm, rates of coronary revascularization were higher in the initial year (hazard ratio [HR], 1.21; p < 0.04), but lower after 1 year (HR, 0.59; p = 0.02).
Conclusions:
The reduced rate of adverse events was noted in patients randomized to CTA across chest pain groups. There was a consistent increase in antiplatelet and statin therapy in the CTA cohort during the follow-up period, which may contribute to the results of this study.
Perspective:
Until recently, there was a lack of robust data demonstrating the effect of coronary CTA on patient outcomes. The SCOT-HEART trial randomized stable chest pain patients to usual care or CTA with usual care and observed a reduction in adverse events among subjects randomized to CTA. This post hoc analysis from the SCOT-HEART trial finds lower rates of adverse events in each symptom category with a sustained increase in both antiplatelet and statin medications in the CTA arm. CTA was also associated with increased coronary revascularization during the first year but decreased rates of interventions after the initial year. While the study cannot determine that these management differences caused the improved patient outcomes, such an effect is certainly possible, and this supports future research evaluating this relationship. These findings support the use of coronary CTA in patients with stable chest pain as an effective means to identify and manage CHD and to improve patient outcomes.
Keywords: Angina Pectoris, Chest Pain, Coronary Angiography, Coronary Disease, Diagnostic Imaging, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Outcome Assessment, Health Care, Platelet Aggregation Inhibitors, Tomography, Emission-Computed
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