Links To And Abstract From The SCOT-HEART Trial With Additional Resources

Coronary CT Angiography and 5-Year Risk of Myocardial Infarction from The SCOT-HEART Investigators [PubMed Abstract] [Full Text HTML] [Full Text PDF]. N Engl J Med. 2018 Sep 6;379(10):924-933. doi: 10.1056/NEJMoa1805971. Epub 2018 Aug 25.

Abstract

BACKGROUND

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.

METHODS

In an open-label, multicenter, parallel-group trial, we randomly assigned 4146 patients with stable chest pain who had been referred to a cardiology clinic for evaluation to standard care plus CTA (2073 patients) or to standard care alone (2073 patients). Investigations, treatments, and clinical outcomes were assessed over 3 to 7 years of follow-up. The primary end point was death from coronary heart disease or nonfatal myocardial infarction at 5 years.

RESULTS

The median duration of follow-up was 4.8 years, which yielded 20,254 patientyears of follow-up. The 5-year rate of the primary end point was lower in the CTA group than in the standard-care group (2.3% [48 patients] vs. 3.9% [81 patients]; hazard ratio, 0.59; 95% confidence interval [CI], 0.41 to 0.84; P=0.004). Although the rates of invasive coronary angiography and coronary revascularization were
higher in the CTA group than in the standard-care group in the first few months of follow-up, overall rates were similar at 5 years: invasive coronary angiography was performed in 491 patients in the CTA group and in 502 patients in the standard-care group (hazard ratio, 1.00; 95% CI, 0.88 to 1.13), and coronary revascularization was performed in 279 patients in the CTA group and in 267 in the standard-care group (hazard ratio, 1.07; 95% CI, 0.91 to 1.27). However, more preventive therapies were initiated in patients in the CTA group (odds ratio, 1.40; 95% CI, 1.19 to 1.65), as were more antianginal therapies (odds ratio, 1.27; 95% CI, 1.05 to 1.54). There were no significant between-group differences in the rates of cardiovascular or noncardiovascular deaths or deaths from any cause.

CONCLUSIONS

In this trial, the use of CTA in addition to standard care in patients with stable chest pain resulted in a significantly lower rate of death from coronary heart disease or nonfatal myocardial infarction at 5 years than standard care alone, without resulting in a significantly higher rate of coronary angiography or coronary revascularization. (Funded by the Scottish Government Chief Scientist Office and others;
SCOT-HEART ClinicalTrials.gov number, NCT01149590.)

The statements from the abstract confused me.

In the Results section of the Abstract, the authors state:

There were no significant between-group differences in the rates of cardiovascular or noncardiovascular deaths or deaths from any cause.*

*The two groups consisted of patients referred to a cardiology clinic with stable chest pain randomized into two groups. One group of patients with stable chest pain was given standard [evaluation and] care. And the second group of patients with stable chest pain was given standard [evaluation and] care and in addition receiving a CT angiogram as part of the workup.

But in the Conclusions section, the authors state

In this trial, the use of CTA in addition to standard care in patients with stable chest pain resulted in a significantly lower rate of death from coronary heart disease or nonfatal myocardial infarction at 5 years than standard care alone, without resulting in a significantly higher rate of coronary angiography or coronary revascularization.

The two statements seem to contradict one another.

*For insight into recommendations for standard evaluation of patients with stable chest pain, please see:

Comparison of International Guidelines for Assessment of Suspected Stable Angina: Insights From the PROMISE and SCOT-HEART [PubMed Abstract] [Full Text HTML] [Full Text PubReader]. JACC Cardiovasc Imaging. 2018 Sep;11(9):1301-1310. doi: 10.1016/j.jcmg.2018.06.021.
When Can We Defer Testing for Patients With Stable Chest Pain? [PubMed Abstract] [Full Text HTML] [Full Text PDF]. JACC Cardiovasc Imaging. 2018 Sep; 11(9): 1311–1314. doi: 10.1016/j.jcmg.2018.07.017

So here are two additional articles I reviewed after doing a Google search “What does the SCOT-HEART Trial mean: