16
views
0
recommends
+1 Recommend
0 collections
    0
    shares
      • Record: found
      • Abstract: found
      • Article: found
      Is Open Access

      Guiding Therapy by Coronary CT Angiography Improves Outcomes in Patients With Stable Chest Pain

      research-article
      , MD, PhD a , b , , , MD, PhD a , c , , MD, PhD a , c , , MD, PhD a , c , , MD a , , MD a , c , , MD a , c , , MD a , c , , MD, PhD d , , MD, PhD e , , PhD f , , MD a , c , , PhD g , , MD, PhD a , c , , MD, PhD h , , MD, PhD c , , MD i , j , , MD j , , MD, PhD i , , MD, DSc a , c , , MD, PhD d , , MD, MPH k , , , MD, PhD d , , SCOT-HEART Investigators
      Journal of the American College of Cardiology
      Elsevier Biomedical
      angina pectoris, computed tomography, coronary heart disease, CI, confidence interval, CTA, computed tomography angiography, HR, hazard ratio, NHS, National Health Service

      Read this article at

      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          Background

          Within the SCOT-HEART (Scottish COmputed Tomography of the HEART Trial) trial of patients with stable chest pain, the use of coronary computed tomography angiography (CTA) reduced the rate of death from coronary heart disease or nonfatal myocardial infarction (primary endpoint).

          Objectives

          This study sought to assess the consistency and mechanisms of the 5-year reduction in this endpoint.

          Methods

          In this open-label trial, 4,146 participants were randomized to standard care alone or standard care plus coronary CTA. This study explored the primary endpoint by symptoms, diagnosis, coronary revascularizations, and preventative therapies.

          Results

          Event reductions were consistent across symptom and risk categories (p = NS for interactions). In patients who were not diagnosed with angina due to coronary heart disease, coronary CTA was associated with a lower primary endpoint incidence rate (0.23; 95% confidence interval [CI]: 0.13 to 0.35 vs. 0.59; 95% CI: 0.42 to 0.80 per 100 patient-years; p < 0.001). In those who had undergone coronary CTA, rates of coronary revascularization were higher in the first year (hazard ratio [HR]: 1.21; 95% CI: 1.01 to 1.46; p = 0.042) but lower beyond 1 year (HR: 0.59; 95% CI: 0.38 to 0.90; p = 0.015). Patients assigned to coronary CTA had higher rates of preventative therapies throughout follow-up (p < 0.001 for all), with rates highest in those with CT-defined coronary artery disease. Modeling studies demonstrated the plausibility of the observed effect size.

          Conclusions

          The beneficial effect of coronary CTA on outcomes is consistent across subgroups with plausible underlying mechanisms. Coronary CTA improves coronary heart disease outcomes by enabling better targeting of preventative treatments to those with coronary artery disease. (Scottish COmputed Tomography of the HEART Trial [SCOT-HEART]; NCT01149590)

          Central Illustration

          Related collections

          Most cited references18

          • Record: found
          • Abstract: found
          • Article: not found

          Coronary CT Angiography and 5-Year Risk of Myocardial Infarction

          (2018)
          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.
            Bookmark
            • Record: found
            • Abstract: found
            • Article: found
            Is Open Access

            High-sensitivity cardiac troponin I at presentation in patients with suspected acute coronary syndrome: a cohort study

            Summary Background Suspected acute coronary syndrome is the commonest reason for emergency admission to hospital and is a large burden on health-care resources. Strategies to identify low-risk patients suitable for immediate discharge would have major benefits. Methods We did a prospective cohort study of 6304 consecutively enrolled patients with suspected acute coronary syndrome presenting to four secondary and tertiary care hospitals in Scotland. We measured plasma troponin concentrations at presentation using a high-sensitivity cardiac troponin I assay. In derivation and validation cohorts, we evaluated the negative predictive value of a range of troponin concentrations for the primary outcome of index myocardial infarction, or subsequent myocardial infarction or cardiac death at 30 days. This trial is registered with ClinicalTrials.gov (number NCT01852123). Findings 782 (16%) of 4870 patients in the derivation cohort had index myocardial infarction, with a further 32 (1%) re-presenting with myocardial infarction and 75 (2%) cardiac deaths at 30 days. In patients without myocardial infarction at presentation, troponin concentrations were less than 5 ng/L in 2311 (61%) of 3799 patients, with a negative predictive value of 99·6% (95% CI 99·3–99·8) for the primary outcome. The negative predictive value was consistent across groups stratified by age, sex, risk factors, and previous cardiovascular disease. In two independent validation cohorts, troponin concentrations were less than 5 ng/L in 594 (56%) of 1061 patients, with an overall negative predictive value of 99·4% (98·8–99·9). At 1 year, these patients had a lower risk of myocardial infarction and cardiac death than did those with a troponin concentration of 5 ng/L or more (0·6% vs 3·3%; adjusted hazard ratio 0·41, 95% CI 0·21–0·80; p<0·0001). Interpretation Low plasma troponin concentrations identify two-thirds of patients at very low risk of cardiac events who could be discharged from hospital. Implementation of this approach could substantially reduce hospital admissions and have major benefits for both patients and health-care providers. Funding British Heart Foundation and Chief Scientist Office (Scotland).
              Bookmark
              • Record: found
              • Abstract: found
              • Article: not found

              Aspirin, heparin, or both to treat acute unstable angina.

              We tested the usefulness of aspirin (325 mg twice daily), heparin (1000 units per hour by intravenous infusion), and a combination of the two in the early management of acute unstable angina pectoris in a double-blind, randomized, placebo-controlled trial involving 479 patients. The patients entered the study as soon as possible after hospital admission (at a mean [+/- SD] of 7.9 +/- 8.0 hours after the last episode of pain), and the study was ended after 6 +/- 3 days, when definitive therapy had been selected. Major end points--refractory angina, myocardial infarction, and death--occurred in 23, 12, and 1.7 percent of the 118 patients receiving placebo, respectively. Heparin was associated with a decrease in the occurrence of refractory angina (P = 0.002). The incidence of myocardial infarction was significantly reduced in the groups receiving aspirin (3 percent; P = 0.01), heparin (0.8 percent; P less than 0.001), and aspirin plus heparin (1.6 percent, P = 0.003), and no deaths occurred in these groups. There were too few deaths overall to permit evaluation of the effect of treatment on this end point. The combination of aspirin and heparin had no greater protective effect than heparin alone but was associated with slightly more serious bleeding (3.3 vs. 1.7 percent). We conclude that in the acute phase of unstable angina, either aspirin or heparin treatment is associated with a reduced incidence of myocardial infarction, and there is a trend favoring heparin over aspirin. Heparin treatment is also associated with a reduced incidence of refractory angina.
                Bookmark

                Author and article information

                Contributors
                Journal
                J Am Coll Cardiol
                J. Am. Coll. Cardiol
                Journal of the American College of Cardiology
                Elsevier Biomedical
                0735-1097
                1558-3597
                22 October 2019
                22 October 2019
                : 74
                : 16
                : 2058-2070
                Affiliations
                [a ]British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
                [b ]Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
                [c ]Edinburgh Imaging, Queen’s Medical Research Institute University of Edinburgh, Edinburgh, United Kingdom
                [d ]Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
                [e ]Norwich Medical School, University of East Anglia, Norwich, United Kingdom
                [f ]Health Research Institute, University of Limerick, Limerick, Ireland
                [g ]Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, United Kingdom
                [h ]William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
                [i ]Ichan School of Medicine and Mount Sinai Hospital, Mount Sinai Heart, New York, New York
                [j ]St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
                [k ]Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
                Author notes
                [] Address for correspondence: Dr. Philip D. Adamson, Christchurch Heart Institute, University of Otago, PO Box 4345, Christchurch 8140, New Zealand. philip.adamson@ 123456cdhb.health.nz
                [∗]

                Drs. McAllister and Berry contributed equally to this paper.

                Article
                S0735-1097(19)37439-X
                10.1016/j.jacc.2019.07.085
                6899446
                31623764
                470e8cfc-d1af-4d39-9a73-4a0ab07c309f
                © 2019 The Authors

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

                History
                : 16 April 2019
                : 23 July 2019
                : 28 July 2019
                Categories
                Article

                Cardiovascular Medicine
                angina pectoris,computed tomography,coronary heart disease,ci, confidence interval,cta, computed tomography angiography,hr, hazard ratio,nhs, national health service

                Comments

                Comment on this article

                scite_

                Similar content197

                Cited by43

                Most referenced authors1,206