Scottish COmputed Tomography Of The HEART Research Articles

Anti-MDA-LDL antibody levels indicate protection from coronary CT-derived valve calcification in the SCOT-HEART Trial

Abstract Introduction Coronary CT-derived valve calcification is becoming increasingly important in the multi-modality assessment of valvular disease, especially in aortic and mitral stenosis, where trans-catheter structural heart interventions may be indicated. Separately, natural antibodies targeted against malondialdehyde-modified LDL (MDA-LDL), an important subset of all oxidised low-density lipoproteins, are related to less coronary atherosclerosis and freedom from cardiovascular events. Purpose To investigate possible relationships between coronary CT-derived valve calcification and anti-MDA-LDL antibodies. Methods In a substudy of the multicentre randomised controlled SCOT-HEART trial (Scottish COmputed Tomography of the HEART), we investigated the association between manually assessed presence or absence of mitral and aortic valve calcification and IgM/ IgG anti-MDA-LDL antibodies. Serological biomarkers were measured using laboratory-developed enzyme-linked immunosorbent assays and assessed in tertiles versus imaging parameters, with adjustment for the ASSIGN cardiovascular risk score. Results In 830 patients (53% male, 57.6±9.8 years) with a heavy burden of cardiovascular risk factors (36% hypertension, 12% diabetes mellitus and 55% history of current or ex-smoking), the highest tertile of IgM anti-MDA-LDL related to a lower incidence of aortic valve calcification (odds ratio [95% confidence interval], 0.59 [0.36 – 0.96], p=0.04, p=0.07 for trend across tertiles) and mitral valve calcification (0.26 [0.07–0.72], p=0.02, p=0.05 for trend). There was also a trend for the highest tertile of IgG anti-MDA-LDL antibodies relating to a lower incidence of aortic valve calcification (0.36 [0.10–0.99], p=0.05, p=0.25 for trend), but not for mitral valve calcification. Conclusions Anti-MDA-LDL antibody levels were associated with a lower incidence of aortic and mitral valve calcification. Assessment of these novel biomarkers, which are known to relate to freedom from cardiovascular events, may be useful in screening patients prior to coronary CT for planning suitability for trans-catheter structural heart interventions.

Deep-Learning for Epicardial Adipose Tissue Assessment With Computed Tomography: Implications for Cardiovascular Risk Prediction

BackgroundEpicardial adipose tissue (EAT) volume is a marker of visceral obesity that can be measured in coronary computed tomography angiograms (CCTA). The clinical value of integrating this measurement in routine CCTA interpretation has not been documented. ObjectivesThis study sought to develop a deep-learning network for automated quantification of EAT volume from CCTA, test it in patients who are technically challenging, and validate its prognostic value in routine clinical care. MethodsThe deep-learning network was trained and validated to autosegment EAT volume in 3,720 CCTA scans from the ORFAN (Oxford Risk Factors and Noninvasive Imaging Study) cohort. The model was tested in patients with challenging anatomy and scan artifacts and applied to a longitudinal cohort of 253 patients post-cardiac surgery and 1,558 patients from the SCOT-HEART (Scottish Computed Tomography of the Heart) Trial, to investigate its prognostic value. ResultsExternal validation of the deep-learning network yielded a concordance correlation coefficient of 0.970 for machine vs human. EAT volume was associated with coronary artery disease (odds ratio [OR] per SD increase in EAT volume: 1.13 [95% CI: 1.04-1.30]; P = 0.01), and atrial fibrillation (OR: 1.25 [95% CI: 1.08-1.40]; P = 0.03), after correction for risk factors (including body mass index). EAT volume predicted all-cause mortality (HR per SD: 1.28 [95% CI: 1.10-1.37]; P = 0.02), myocardial infarction (HR: 1.26 [95% CI:1.09-1.38]; P = 0.001), and stroke (HR: 1.20 [95% CI: 1.09-1.38]; P = 0.02) independently of risk factors in SCOT-HEART (5-year follow-up). It also predicted in-hospital (HR: 2.67 [95% CI: 1.26-3.73]; P ≤ 0.01) and long-term post–cardiac surgery atrial fibrillation (7-year follow-up; HR: 2.14 [95% CI: 1.19-2.97]; P ≤ 0.01). ConclusionsAutomated assessment of EAT volume is possible in CCTA, including in patients who are technically challenging; it forms a powerful marker of metabolically unhealthy visceral obesity, which could be used for cardiovascular risk stratification.

Pericoronary Adipose Tissue Attenuation, Low-Attenuation Plaque Burden, and 5-Year Risk of Myocardial Infarction

BackgroundPericoronary adipose tissue (PCAT) attenuation and low-attenuation noncalcified plaque (LAP) burden can both predict outcomes. ObjectivesThis study sought to assess the relative and additive values of PCAT attenuation and LAP to predict future risk of myocardial infarction. MethodsIn a post hoc analysis of the multicenter SCOT-HEART (Scottish Computed Tomography of the Heart) trial, the authors investigated the relationships between the future risk of fatal or nonfatal myocardial infarction and PCAT attenuation measured from coronary computed tomography angiography (CTA) using multivariable Cox regression models including plaque burden, obstructive coronary disease, and cardiac risk score (incorporating age, sex, diabetes, smoking, hypertension, hyperlipidemia, and family history). ResultsIn 1,697 evaluable participants (age: 58 ± 10 years), there were 37 myocardial infarctions after a median follow-up of 4.7 years. Mean PCAT was −76 ± 8 HU and median LAP burden was 4.20% (IQR: 0%-6.86%). PCAT attenuation of the right coronary artery (RCA) was predictive of myocardial infarction (HR: 1.55; P = 0.017, per 1 SD increment) with an optimum threshold of −70.5 HU (HR: 2.45; P = 0.01). In multivariable analysis, adding PCAT-RCA of ≥−70.5 HU to an LAP burden of >4% (the optimum threshold for future myocardial infarction; HR: 4.87; P < 0.0001) led to improved prediction of future myocardial infarction (HR: 11.7; P < 0.0001). LAP burden showed higher area under the curve compared to PCAT attenuation for the prediction of myocardial infarction (AUC = 0.71 [95% CI: 0.62-0.80] vs AUC = 0.64 [95% CI: 0.54-0.74]; P < 0.001), with increased area under the curve when the 2 metrics are combined (AUC = 0.75 [95% CI: 0.65-0.85]; P = 0.037). ConclusionCoronary CTA–defined LAP burden and PCAT attenuation have marked and complementary predictive value for the risk of fatal or nonfatal myocardial infarction.

Deep learning-based plaque quantification from coronary computed tomography angiography: external validation and comparison with intravascular ultrasound

Abstract Background Atherosclerotic plaque quantification from coronary computed tomography angiography (CTA) enables accurate assessment of coronary artery disease burden, progression, and prognosis. However, quantitative plaque analysis is time-consuming and requires high expertise. We sought to develop and externally validate an artificial intelligence (AI)-based deep learning (DL) approach for CTA-derived measures of plaque volume and stenosis severity. We compared the performance of DL to expert readers and the gold standard of intravascular ultrasound (IVUS). Methods This was a multicenter study of patients undergoing coronary CTA at 11 sites, with software-based quantitative plaque measurements performed at a per-lesion level by expert readers. AI-based plaque analysis was performed by a DL novel convolutional neural network which automatically segmented the coronary artery wall, lumen, and plaque for the computation of plaque volume and stenosis severity. Using expert measurements as ground truth, the DL algorithm was trained on 887 patients (4,686 lesions). Thereafter, the algorithm was applied to an independent test set of 221 patients (1,234 lesions), which included an external validation cohort of 171 patients from the SCOT-HEART (Scottish Computed Tomography of the Heart) trial as well as 50 patients who underwent IVUS within one month of CTA. We report the performance of AI-based plaque analysis in the independent test set. Results Within the external validation cohort, there was excellent agreement between DL and expert reader measurements of total plaque volume (intraclass correlation coefficient [ICC] 0.876), noncalcified plaque volume (ICC 0.869), and percent diameter stenosis (ICC 0.850; all p&amp;lt;0.001). When compared with IVUS, there was excellent agreement for DL total plaque volume (ICC 0.945), total plaque burden (ICC 0.853), minimal luminal area (ICC 0.864), and percent area stenosis (ICC 0.805; all p&amp;lt;0.001); with strong correlation between DL and IVUS for total plaque volume (r=0.915; p&amp;lt;0.001; Figure). The average DL plaque analysis time was 20 seconds per patient, compared with 25–30 minutes taken by experts. Conclusions AI-based plaque quantification from coronary CTA using an externally validated DL approach enables rapid measurements of plaque volume and stenosis severity in close agreement with expert readers and IVUS. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Heart, Lung, and Blood Institute, United States

Cardiac Computed Tomography for Personalized Management of Patients With Type 2 Diabetes Mellitus.

The incidence and prevalence of type 2 diabetes mellitus are increasing in the United States and worldwide. The individual-level risk of atherosclerotic cardiovascular disease events in primary prevention populations with type 2 diabetes mellitus is highly heterogeneous. Accurate risk stratification in this group is paramount to optimize the use of preventive therapies. Herein, we review the use of the coronary artery calcium score as a decision aid in individuals with type 2 diabetes mellitus without clinical atherosclerotic cardiovascular disease to guide the use of preventive pharmacotherapies, such as aspirin, lipid-lowering mediations, and cardiometabolic agents. The magnitude of expected risk reduction for each of these therapies must be weighed against its cost and potential adverse events. Coronary artery calcium has the potential to improve risk stratification in select individuals beyond clinical and laboratory risk factors, thus providing a more granular assessment of the expected net benefit with each therapy. In patients with diabetes mellitus and stable chest pain, coronary computed tomography angiography increases the sensitivity for coronary artery disease diagnoses compared with functional studies because of the detection of nonobstructive atherosclerosis. Most importantly, this anatomic approach may improve cardiovascular outcomes by increasing the use of evidence-based preventive therapies informed by plaque burden. We therefore provide an updated discussion of the pivotal role of coronary computed tomography angiography in the workup of stable chest pain in patients with diabetes mellitus in the context of recent landmark trials, such as PROMISE trial (Prospective Multicenter Imaging Study for Evaluation of Chest Pain), SCOT-HEART trial (Scottish Computed Tomography of the Heart), and ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches). Finally, we also outline the current role of coronary computed tomography angiography in acute chest pain presentations.

Outcomes of anatomical vs. functional testing for coronary artery disease : Lessons from the major trials.

Management of patients presenting with suspected stable coronary artery disease (CAD) are challenging because estimation of pretest probability for obstructive CAD remains difficult. In addition, identification of those who benefit from coronary revascularization remains ineffective regardless of the wide array of noninvasive testing alternatives available. Functional testing, which has long been considered to be the test of choice to risk stratify these patients, shows modest agreement with CAD severity detected by invasive coronary angiography and has been reported to be ineffective in settings of low prevalence of obstructive CAD. Agrowing body of evidence demonstrates the excellent diagnostic accuracy as well as prognostic value of coronary computed tomography (CT) angiography especially in conjunction with noninvasive fractional flow reserve (FFR) testing, challenging the primary role of functional testing especially in patients without prior or known CAD. Landmark trials, including the Prospective Multicenter Imaging Study for Evaluation of chest pain (PROMISE) and Scottish Computed Tomography of the Heart (SCOT-HEART), have contributed to abetter understanding of how coronary CT angiography may play arole in more efficient management and even improved health outcomes. The emerging role of coronary CT has been acknowledged by the 2019 Guidelines of the European Society of Cardiology recommending the use of CT as afirst-line tool for the evaluation of patients with stable chest pain with aclassI, level of evidenceB recommendation. The purpose of this article is to provide an overview on existing evidence, clinical implication, limitations of available data, and remaining questions to be answered by future research.

Exercise Electrocardiography and Computed Tomography Coronary Angiography for Patients With Suspected Stable Angina Pectoris

Recent European guidance supports a diminished role for exercise electrocardiography (ECG) in the assessment of suspected stable angina. To evaluate the utility of exercise ECG in contemporary practice and assess the value of combined functional and anatomical testing. This is a post hoc analysis of the Scottish Computed Tomography of the Heart (SCOT-HEART) open-label randomized clinical trial, conducted in 12 cardiology chest pain clinics across Scotland for patients with suspected angina secondary to coronary heart disease. Between November 18, 2010, and September 24, 2014, 4146 patients aged 18 to 75 years with stable angina underwent clinical evaluation and 1417 of 1651 (86%) underwent exercise ECG prior to randomization. Statistical analysis was conducted from October 10 to November 5, 2019. Patients were randomized in a 1:1 ratio to receive standard care plus coronary computed tomography (CT) angiography or to receive standard care alone. The present analysis was limited to the 3283 patients who underwent exercise ECG alone or in combination with coronary CT angiography. The primary clinical end point was death from coronary heart disease or nonfatal myocardial infarction at 5 years. Among the 3283 patients (1889 men; median age, 57.0 years [interquartile range, 50.0-64.0 years]), exercise ECG had a sensitivity of 39% and a specificity of 91% for detecting any obstructive coronary artery disease in those who underwent subsequent invasive angiography. Abnormal results of exercise ECG were associated with a 14.47-fold (95% CI, 10.00-20.41; P < .001) increase in coronary revascularization at 1 year and a 2.57-fold (95% CI, 1.38-4.63; P < .001) increase in mortality from coronary heart disease death at 5 years or in cases of nonfatal myocardial infarction at 5 years. Compared with exercise ECG alone, results of coronary CT angiography had a stronger association with 5-year coronary heart disease death or nonfatal myocardial infarction (hazard ratio, 10.63; 95% CI, 2.32-48.70; P = .002). The greatest numerical difference in outcome with CT angiography compared with exercise ECG alone was observed for those with inconclusive results of exercise ECG (5 of 285 [2%] vs 13 of 283 [5%]), although this was not statistically significant (log-rank P = .05). This study suggests that abnormal results of exercise ECG are associated with coronary revascularization and the future risk of adverse coronary events. However, coronary CT angiography more accurately detects coronary artery disease and is more strongly associated with future risk compared with exercise ECG. ClinicalTrials.gov Identifier: NCT01149590.

SCOT-HEART trial: reshuffling our approach to stable ischemic heart disease.

The role of diagnostic testing in triaging patients with stable ischemic heart disease continues to evolve towards recognizing the benefits of coronary CT angiography (CCTA) over functional testing. The SCOT-HEART (Scottish Computed Tomography of the HEART) trial highlights this paradigm shift finding a significant reduction of death from coronary heart disease or non-fatal myocardial infarction without a significant increased rate of invasive coronary angiography over a 5 year follow-up period when implementing CCTA with standard care vs standard care alone. The better negative predictive value and ability to identify nonobstructive coronary artery disease to optimize medical therapy highlight the benefits of a CCTA first strategy. With the advent of noninvasive fractional flow reserve (FFR) and widespread availability and ease of CT, CCTA continues to establish itself as a pivotal diagnostic exam for patients with stable ischemic heart disease. In this commentary, we review the SCOT-HEART trial and its impact on CCTA for patients with stable ischemic heart disease.

Standardized reporting systems for computed tomography coronary angiography and calcium scoring: A real-world validation of CAD-RADS and CAC-DRS in patients with stable chest pain

ObjectivesTo assess the prognostic implications of standardized reporting systems for coronary computed tomography angiography (CCTA) and coronary artery calcium scores (CACS) in patients with stable chest pain. BackgroundThe Coronary Artery Disease Reporting And Data System (CAD-RADS) and Coronary Artery Calcium – Data and Reporting System (CAC-DRS) aim to improve communication of CACS and CCTA results, but its influence on prognostication is unknown. MethodsImages from 1769 patients who underwent CCTA as part of the Scottish Computed Tomography of the HEART (SCOT-HEART) multi-center randomized controlled trial were assessed. CACS were classified as CAC-DRS 0 to 3 based on Agatston scores. CCTA were classified as CAD-RADS 0 to 5 based on the most clinically relevant finding per patient. The primary outcome was the five-year events of fatal and non-fatal myocardial infarction. ResultsPatients had a mean age of 58 ± 10 years and 56% were male. CAC-DRS 0, 1, 2 and 3 occurred in 642 (36%), 510 (29%), 239 (14%) and 379 (21%) patients respectively. CAD-RADS 0, 1, 2, 3, 4A, 4B and 5 occurred in 622 (35%), 327 (18%), 211 (12%), 165 (9%), 221 (12%), 42 (2%) and 181 (10%) patients respectively. Patients classified as CAC-DRS 3 were at an increased risk of fatal or non-fatal myocardial infarction compared to CAC-DRS 0 patients (hazard ratio (HR) 9.41; 95% confidence interval (CI) 3.24, 27.31; p < 0.001). Patients with higher CAD-RADS categories were at an increased risk of fatal or non-fatal myocardial infarction, with patients classified as CAD-RADS 4B at the highest risk compared to CAD-RADS 0 patients (HR 19.14; 95% CI 4.28, 85.53; p < 0.001). ConclusionPatients with higher CAC-DRS and CAD-RADS scores were at increased risk of subsequent fatal and non-fatal myocardial infarction. This confirms that the classification provides additional prognostic discrimination for future coronary heart disease events.

Comparison of International Guidelines for Assessment of Suspected Stable Angina: Insights From the PROMISE and SCOT-HEART

ObjectivesThis study sought to compare the performance of major guidelines for the assessment of stable chest pain including risk-based (American College of Cardiology/American Heart Association and European Society of Cardiology) and symptom-focused (National Institute for Health and Care Excellence) strategies. BackgroundAlthough noninvasive testing is not recommended in low-risk individuals with stable chest pain, guidelines recommend differing approaches to defining low-risk patients. MethodsPatient-level data were obtained from the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) and SCOT-HEART (Scottish Computed Tomography of the Heart) trials. Pre-test probability was determined and patients dichotomized into low-risk and intermediate-high–risk groups according to each guideline’s definitions. The primary endpoint was obstructive coronary artery disease on coronary computed tomography angiography. Secondary endpoints were coronary revascularization at 90 days and cardiovascular death or nonfatal myocardial infarction up to 3 years. ResultsIn total, 13,773 patients were included of whom 6,160 had coronary computed tomography angiography. The proportions of patients identified as low risk by the American College of Cardiology/American Heart Association, European Society of Cardiology, and National Institute for Health and Care Excellence guidelines, respectively, were 2.5%, 2.5%, and 10.0% within PROMISE, and 14.0%, 19.8%, and 38.4% within SCOT-HEART. All guidelines identified lower rates of obstructive coronary artery disease in low- versus intermediate-high–risk patients with a negative predictive value of ≥0.90. Compared with low-risk groups, all intermediate-high–risk groups had greater risks of coronary revascularization (odds ratio [OR]: 2.2 to 24.1) and clinical outcomes (OR: 1.84 to 5.8). ConclusionsCompared with risk-based guidelines, symptom-focused assessment identifies a larger group of low-risk chest pain patients potentially deriving limited benefit from noninvasive testing. (Scottish Computed Tomography of the Heart Trial [SCOT-HEART]; NCT01149590; Prospective Multicenter Imaging Study for Evaluation of Chest Pain [PROMISE]; NCT01174550)

Highlights From the Circulation Family of Journals

Highlights From the <i>Circulation</i> Family of Journals

High-Sensitivity Cardiac Troponin I and the Diagnosis of Coronary Artery Disease in Patients With Suspected Angina Pectoris.

We determined whether high-sensitivity cardiac troponin I can improve the estimation of the pretest probability for obstructive coronary artery disease (CAD) in patients with suspected stable angina. In a prespecified substudy of the SCOT-HEART trial (Scottish Computed Tomography of the Heart), plasma cardiac troponin was measured using a high-sensitivity single-molecule counting assay in 943 adults with suspected stable angina who had undergone coronary computed tomographic angiography. Rates of obstructive CAD were compared with the pretest probability determined by the CAD Consortium risk model with and without cardiac troponin concentrations. External validation was undertaken in an independent study population from Denmark comprising 487 patients with suspected stable angina. Higher cardiac troponin concentrations were associated with obstructive CAD with a 5-fold increase across quintiles (9%-48%; P<0.001) independent of known cardiovascular risk factors (odds ratio, 1.35; 95% confidence interval, 1.25-1.46 per doubling of troponin). Cardiac troponin concentrations improved the discrimination and calibration of the CAD Consortium model for identifying obstructive CAD (C statistic, 0.788-0.800; P=0.004; χ2=16.8 [P=0.032] to 14.3 [P=0.074]). The updated model also improved classification of the American College of Cardiology/American Heart Association pretest probability risk categories (net reclassification improvement, 0.062; 95% confidence interval, 0.035-0.089). The revised model achieved similar improvements in discrimination and calibration when applied in the external validation cohort. High-sensitivity cardiac troponin I concentration is an independent predictor of obstructive CAD in patients with suspected stable angina. Use of this test may improve the selection of patients for further investigation and treatment. URL: https://www.clinicaltrials.gov. Unique identifier: NCT01149590.

Impact of noncardiac findings in patients undergoing CT coronary angiography: a substudy of the Scottish computed tomography of the heart (SCOT-HEART) trial

ObjectivesNoncardiac findings are common on coronary computed tomography angiography (CCTA). We assessed the clinical impact of noncardiac findings, and potential changes to surveillance scans with the application of new lung nodule guidelines.MethodsThis substudy of the SCOT-HEART randomized controlled trial assessed noncardiac findings identified on CCTA. Clinically significant noncardiac findings were those causing symptoms or requiring further investigation, follow-up or treatment. Lung nodule follow-up was undertaken following the 2005 Fleischner guidelines. The potential impact of the 2015 British Thoracic Society (BTS) and the 2017 Fleischner guidelines was assessed.ResultsCCTA was performed in 1,778 patients and noncardiac findings were identified in 677 (38%). In 173 patients (10%) the abnormal findings were clinically significant and in 55 patients (3%) the findings were the cause of symptoms. Follow-up imaging was recommended in 136 patients (7.6%) and additional clinic consultations were organized in 46 patients (2.6%). Malignancy was diagnosed in 7 patients (0.4%). Application of the new lung nodule guidelines would have reduced the number of patients undergoing a follow-up CT scan: 68 fewer with the 2015 BTS guidelines and 78 fewer with the 2017 Fleischner guidelines; none of these patients subsequently developed malignancy.ConclusionsClinically significant noncardiac findings are identified in 10% of patients undergoing CCTA. Application of new lung nodule guidelines will reduce the cost of surveillance, without the risk of missing malignancy.Key Points• Clinically significant noncardiac findings occur in 10% of patients undergoing CCTA.• Noncardiac findings may be an important treatable cause of chest pain• Further imaging investigations for noncardiac findings were recommended in 8% of patients after CCTA.• New lung nodule follow-up guidelines will result in cost savings.

Identification of patients with stable chest pain deriving minimal value from coronary computed tomography angiography: An external validation of the PROMISE minimal-risk tool.

BackgroundThe PROspective Multicenter Imaging Study for Evaluation of chest pain (PROMISE) minimal-risk tool was recently developed to identify patients with suspected stable angina at very low risk of coronary artery disease (CAD) and clinical events. We assessed the external validity of this tool within the context of the Scottish Computed Tomography of the HEART (SCOT-HEART) multicenter randomised controlled trial of patients with suspected stable angina due to coronary disease.MethodsThe minimal-risk tool was applied to 1764 patients with complete imaging and follow-up data. External validity was compared with the guideline-endorsed CAD Consortium (CADC) risk score and determined through tests of model discrimination and calibration.ResultsA total of 531 (30.1%, mean age 52.4 years, female 62.0%) patients were classified as minimal-risk. Compared to the remainder of the validation cohort, this group had lower estimated pre-test probability of coronary disease according to the CADC model (30.0% vs 47.0%, p < 0.001). The PROMISE minimal-risk tool improved discrimination compared with the CADC model (c-statistic 0.785 vs 0.730, p < 0.001) and was improved further following re-estimation of covariate coefficients (c-statistic 0.805, p < 0.001). Model calibration was initially poor (χ2 197.6, Hosmer-Lemeshow [HL] p < 0.001), with significant overestimation of probability of minimal risk, but improved significantly following revision of the PROMISE minimal-risk intercept and covariate coefficients (χ2 5.6, HL p = 0.692).Conclusion and relevanceDespite overestimating the probability of minimal-risk, the PROMISE minimal-risk tool outperforms the CADC model with regards to prognostic discrimination in patients with suspected stable angina, and may assist clinicians in decisions regarding non-invasive testing.Trial registrationClinicalTrials.gov identifier: NCT01149590

1013Diagnostic and prognostic benefits of CTCA using the updated NICE guidance: An analysis of the Scottish computed tomography of the heart (SCOT-HEART) trial

1013Diagnostic and prognostic benefits of CTCA using the updated NICE guidance: An analysis of the Scottish computed tomography of the heart (SCOT-HEART) trial

Diagnostic and Prognostic Benefits of CTCA Using the Updated NICE Guidance: An Analysis of the Scottish COmputed Tomography of the HEART (SCOT-HEART) trial

Objectives: To evaluate the diagnostic and prognostic benefits of computed tomography coronary angiography (CTCA) when employed in accordance with the updated UK National Institute for Health and Care Excellence (NICE) guidelines for the assessment of suspected stable angina. Methods: Post-hoc analysis of the Scottish COmputed Tomography of the HEART (SCOT-HEART) multicentre trial which randomised participants with suspected angina to standard care or CTCA. Patients were dichotomised based on symptoms and the resting electrocardiogram in accordance with the NICE definitions for possible angina and non-anginal presentations. The primary (diagnostic) endpoint was diagnostic certainty of angina at 6 weeks. The long-term prognostic endpoint comprised a composite of fatal and non-fatal myocardial infarction (MI). Results: 3,770 participants were randomised and follow-up was 3.2 years. CTCA increased diagnostic certainty. This benefit was greatest (pinteraction < 0.001) in those with possible angina (CTCA 34.9%, standard care 15.7%; RR 2.22, 95% CI 1.91 to 2.60, p < 0.001). This was attenuated in the non-anginal cohort (CTCA 32%, standard care 25.2%; RR 1.30, 95% CI 1.11 to 1.53, p = 0.002). CTCA reduced the likelihood of fatal or non-fatal MI in the cohort with possible angina from 3.2% to 1.9% (HR 0.58; 95% CI 0.34 to 0.99; p = 0.045). This reduction in clinical events was not statistically significant in the non-anginal cohort (HR 0.65; 95% CI 0.25 to 1.69; p = 0.379) (pinteraction = 0.836). Conclusions: The 2016 NICE guideline suitably identifies patients requiring further investigation of angina. Within this context, the use of CTCA is associated with greater diagnostic certainty and a reduced risk of myocardial infarction.

Achieving the Full "PROMISE" of Imaging Outcomes Research.

Like many areas in cardiology, ongoing imaging technology development creates a need for high-quality data on how best to incorporate potential game changers such as coronary computed tomographic angiography (CTA) into clinical care. In 2015, several large, outcomes-based, randomized trials compared the use of CTA with stress testing for the diagnosis of stable chest pain, including the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain; NCT01174550), SCOT-HEART (Scottish Computed Tomography of the Heart; NCT01149590), and PLATFORM (Prospective Longitudinal Trial of FFRCT Outcome and Resource Impacts; clinical outcomes of FFRCT-guided diagnostic strategies versus usual care trial; NCT01943903) trials.1–3 Although each of these studies provides evidence that CTA improves diagnostic thinking and catheterization laboratory referral decisions, clinical event rates with CTA and usual care strategies were similar. As a result, although many observers view these trials as establishing new evidence-based testing options, others find them to be insufficiently compelling to change clinical care. This debate aside, digging more deeply into these trials uncovers a great deal of important and novel information about patients with stable chest pain and suspected coronary artery disease, applicable to both clinical care and future research. These data are particularly important given the large size of this population and the dearth of contemporary studies of patients undergoing elective testing for suspected coronary artery disease (CAD). Although all 3 trial cohorts were symptomatic and had a high risk factor burden, they had low cardiovascular event rates, just 1% to 2% per year. This low event rate has prompted some observers to suggest that a strategy of …

Clinical Outcomes After Evaluation of Stable Chest Pain by Coronary Computed Tomographic Angiography Versus Usual Care

Background— Limited data exist on how noninvasive testing options compare for evaluating patients with suspected stable coronary artery disease. In this study, we have performed a meta-analysis of randomized controlled trials comparing the use of coronary computed tomographic angiography (CTA) with usual care. Methods and Results— We systematically searched databases for randomized clinical trials comparing coronary CTA with usual care for the evaluation of stable chest pain with follow-up for cardiovascular outcomes. The primary outcomes were myocardial infarction and all-cause mortality. We identified 4 randomized clinical trials, including a total of 7403 patients undergoing coronary CTA and 7414 patients undergoing usual care with various functional testing approaches. When compared with usual care, the use of coronary CTA was associated with a significant reduction in the annual rate of myocardial infarction (rate ratio, 0.69; 95% confidence interval, 0.49–0.98; P =0.038), but no difference was found in all-cause mortality. There was a trend toward more invasive coronary angiographies among patients undergoing coronary CTA (odds ratio, 1.33; 95% confidence interval, 0.95–1.84; P =0.09) and higher use of coronary revascularizations (odds ratio, 1.77; 95% confidence interval, 1.14–2.75). Significant heterogeneity for invasive coronary angiography and revascularization was noted, which was attributable to the Scottish Computed Tomography of the HEART (SCOT-HEART) study. We found no difference in the rate of admission for cardiac chest pain (rate ratio, 1.21; 95% confidence interval, 0.95–1.54). Conclusions— In comparison to usual care, an initial investigation of suspected stable coronary artery disease using coronary CTA resulted in a significant reduction in myocardial infarction, an increased incidence of coronary revascularization, and no effect in all-cause mortality. Future studies should further define whether the potential reduction in myocardial infarction identified justifies the increased resource utilization associated with coronary CTA.

Coronary CT Angiography as a Diagnostic and Prognostic Tool: Perspectives from the SCOT-HEART Trial.

Coronary artery disease is the leading cause of death worldwide. Many trials to date have investigated the diagnostic accuracy of coronary computed tomography angiography (CCTA) when compared to the gold standard diagnostic test, invasive coronary angiography. However, whether the use of a non-invasive anatomical test, such as CCTA, can translate into improved patient risk stratification, management and outcome has yet to be established. The Scottish COmputed Tomography of the HEART (SCOT-HEART) trial sought to address these questions and determined whether CCTA, when used in addition to standard care, could aid the diagnosis, further investigation and treatment of patients referred to the cardiology clinic with suspected angina due to coronary heart disease. In this trial, CCTA clarified the diagnosis of angina due to coronary heart disease in a quarter of patients and this led to major alterations in treatment and management that appeared to reduce the risk of subsequent coronary heart disease death or non-fatal myocardial infarction. The SCOT-Heart trial has established that CCTA is a valuable diagnostic test in patients with suspected angina pectoris due to coronary heart disease and leads to greater clarity, more focused appropriate treatments and better coronary heart disease outcomes.

Observer variability in the assessment of CT coronary angiography and coronary artery calcium score: substudy of the Scottish COmputed Tomography of the HEART (SCOT-HEART) trial

IntroductionObserver variability can influence the assessment of CT coronary angiography (CTCA) and the subsequent diagnosis of angina pectoris due to coronary heart disease.MethodsWe assessed 210 CTCAs from the Scottish COmputed...