By Michael H. Crawford, MD, Editor
Synopsis: The 10-year follow-up of the SCOT-HEART Study of new-onset chest pain patients randomized to standard care vs. the addition of coronary computed tomography angiography (CTA) has shown that coronary heart disease-related death, myocardial infarction, and other adverse cardiovascular outcomes are reduced with CTA use, perhaps because preventive therapy is increased.
Source: Williams MC, Wereski R, Tuck C, et al. Coronary CT angiography-guided management of patients with stable chest pain: 10-year outcomes from the SCOT-HEART randomised controlled trial in Scotland. Lancet. 2025;405(10475):329-337.
The five-year follow-up results of the Scottish Computed Tomography of the Heart (SCOT-HEART) trial in patients presenting with new-onset chest pain demonstrated that the combined primary endpoint of coronary heart disease (CHD) mortality and nonfatal myocardial infarction (MI) was significantly reduced in the group that received computed tomography angiography (CTA) to guide therapy compared to those who received standard care, without increasing invasive coronary procedures or revascularization. However, since CHD is a progressive disease, there was concern that these results would attenuate over time as the patients aged. Thus, this prespecified 10-year analysis of SCOT-HEART is of interest.
SCOT-HEART is an open-label, multicenter, parallel group randomized controlled trial of stable patients with new-onset chest pain conducted at 12 outpatient chest pain clinics in Scotland, which enrolled 4,146 patients aged 18-75 years between 2010 and 2014 (mean age 57 years, 56% men). Excluded were those with contraindications to CTA or an acute coronary syndrome within three months. The patients were randomized 1:1 to standard care or standard care plus CTA. In both groups, those without contraindications underwent exercise electrocardiogram (ECG) testing as part of standard care.
Clinical data were derived from the Scottish National Health System database, which is linked to the national death database and pharmacy records (in Scotland medications are free). The primary outcome was CHD mortality or MI. Secondary outcomes included the components of the primary combined endpoint, all-cause death, stroke, heart catheterization, coronary revascularization, and major adverse cardiovascular events (MACE) defined as coronary death, MI, or stroke.
Median CT coronary artery calcium score in the patients was 20 Agatston units (range 0-230). CTA exhibited 37% of patients with normal coronary arteries, 38% of patients with nonobstructive CHD, and 24% of patients with obstructive CHD. Ten-year follow-up data were available in 96% of patients. The primary outcome was less frequent in patients in the CTA group (6.6 vs. 8.2%; hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.63-0.99; P = 0.044).
Among the secondary endpoints, only MI (4.3 vs. 6.0; HR, 0.72; 95% CI, 0.55-0.94; P = 0.017) and MACE (8.3% vs. 10%; HR, 0.80; 95% CI, 0.65-0.97; P = 0.026) were statistically different. Also, prevention therapies were more commonly deployed in the CTA group (56% vs. 49%; HR, 1.17; 95% CI, 1.01-1.36; P = 0.034). The authors concluded that CTA-guided management in patients with new-onset chest pain reduced CHD mortality, MI, and MACE over 10 years and increased the use of preventive therapy.
Commentary
Perhaps the most interesting outcome of the 10-year follow-up of the SCOT-HEART trial patients is that there was no significant increase in the use of invasive coronary angiography or revascularization in the standard care group. This has been a major armchair critique of using CT scans in routine care. Of course, these were low-risk patients. They were relatively young (mean age 57 years and all younger than 75 years of age at enrollment). Also, the median CT calcium score was 20 Agatston units and most of the benefit observed was a reduction in nonfatal MI. However, the use of preventive therapies, mainly statin drugs, was increased significantly in the CTA group. This observation is important because some prior short-term studies of CT use in patients with chest pain have shown a decrease in preventive therapies presumed to be the result of the induction of a feeling of doom and helplessness when the patient learns they have CHD.
The major strength of SCOT-HEART is the national linked databases available on patients in Scotland and the 96% 10-year follow-up. There also are limitations. There was no independent adjudication of the endpoints. The management of CHD patients has changed markedly over the last 10 years. It has become more conservative because of several studies that have failed to show mortality reductions with coronary revascularization. Also, CT technology has changed, and newer techniques such as photon-counting to determine coronary flow were not available for SCOT-HEART. In addition, cardiac imaging apparently was not deployed with the ECG stress tests some patients underwent.
Insurance carrier resistance to covering CTA has been a major limiting factor in the United States. This was not helped by the publication of the PROMISE trial, which compared CTA to functional testing for the management of suspected CHD in more than 10,000 patients and showed no difference in outcomes at two years.1 The five-year outcomes of SCOT-HEART were published earlier and showed a significant decrease in the primary endpoint. Perhaps this has softened the insurance companies, because their resistance to CTA is decreasing, at least where I practice. One hopes the 10-year data will stimulate a further decrease in resistance to CTA for the evaluation of patients suspected of having CHD.
Michael H. Crawford, MD, is Professor Emeritus of Medicine and Consulting Cardiologist, UCSF Health, San Francisco.
Reference
1. Douglas PS, Hoffmann U, Patel MR, et al. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med. 2015;372(14):1291-1300.
The 10-year follow-up of the SCOT-HEART Study of new-onset chest pain patients randomized to standard care vs. the addition of coronary computed tomography angiography (CTA) has shown that coronary heart disease-related death, myocardial infarction, and other adverse cardiovascular outcomes are reduced with CTA use, perhaps because preventive therapy is increased.
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