SCOT-Heart Trial finds cardiac CT scan nearly halves future risk of heart attack in patients with chest pain
They say you cannot die from a broken heart, but in fact, cardiovascular disease (CVD) remains the leading cause of death worldwide, killing more than 17 million people every year.
The number one cause of CV death in both men and women is coronary artery disease (CAD), which occurs when the key artery to the heart is blocked by plaque.
Chest pain is a common symptom of this blockage, which, left untreated, can stop blood flow and cause a catastrophic heart attack that many people don’t survive. 1
For decades, the standard of care has been for primary care physicians to refer patients with chest pain to receive cardiology services to determine whether they have CAD. These patients are risk-assessed for CAD, further investigated and treated according to their level of risk. All this is done with the goal of addressing symptoms and reducing the risk of adverse CV outcomes, namely heart attack and death.
However, while this evaluation of chest pain in high risk patients is effective, it has proven challenging in low to intermediate risk patients in whom the likelihood of CAD can sometimes be underestimated.
Fortunately, technological advances in cardiac CT offer a solution.
The SCOT-Heart trial
represents a breakthrough study that demonstrates the value of integrating cardiac CT in standard of care to increase diagnostic confidence compared to standard of care alone.
“This is the first time that CT guided management has been shown to improve patient outcomes with a major reduction in the future risk of heart attacks,” said lead author David Newby, from the British Heart Foundation Centre for Cardiovascular Science at the University of Edinburgh. “This has major implications for how we now investigate and manage patients with suspected heart disease.”
The open label trial randomly assigned 4,146 patients with stable chest pain to receive either standard care plus computed tomography angiography (CTA) or standard care alone. These patients then received follow up care for a median of 4.8 years, offering a total of 20,254 years of patient follow-up data.
Results showed that the rate of either death from coronary heart disease or non-fatal myocardial infarction, or heart attack, was 41% lower in patients undergoing CTA compared with those managed with the traditional standard care (2.3% versus 3.9%, hazard ratio 0.59, 95% confidence interval 0.41 to 0.84, P=0.004). This was driven almost entirely by a lower rate of non-fatal heart attack.
“Our findings suggest that the use of CTA resulted in more correct diagnoses of coronary heart disease than standard care alone, which, in turn, led to the use of appropriate therapies. This change in management resulted in fewer clinical events in the CTA group,” the research group wrote.
Rates of invasive coronary angiography and coronary revascularisation were higher in the CTA group in the first few months, but overall rates were similar at five years. Patients who received CT scans, however, were more likely to be started on preventive therapies than the standard care group (odds ratio 1.40, 95% confidence interval 1.19 to 1.65) and angina drugs (1.27, 1.05 to 1.54).
“This relatively simple heart scan ensures that patients get the right treatment,” said Newby.
In an accompanying editorial, Udo Hoffman of Massachusetts General Hospital and James Udelson of Tufts Medical Center, added, “The information provided by a diagnostic test can resonate therapeutically beyond making a correct diagnosis of coronary artery disease.”
“Taking a picture of the heart with CT requires amazing technology that is ultrafast to freeze the heartbeat motion and is super resolution to see inside the coronary arteries,” added Scott Schubert, General Manager of Premium CT, GE Healthcare. “This is technology we couldn’t have dreamed of a decade ago, but the SCOT-Heart researchers saw this coming, and today the technology can be readily available to hospitals around the world.”
WHO. Cardiovascular diseases (17 May 2017). https://www.who.int/cardiovascular_diseases/world-heart-day/en/
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Balfour PC, et al. Non-invasive assessment of low- and intermediate-risk patients with chest pain. Trends Cardiovasc Med 2017;27(3):182-9
U HoffmannJE Udelson. Imaging coronary anatomy and reducing myocardial infarction. N Engl J Med2018,10.1056/NEJMe1809203. 30145924