Original Investigation
Use of Coronary Computed Tomographic Angiography to Guide Management of Patients With Coronary Disease

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Abstract

Background

In a prospective, multicenter, randomized controlled trial, 4,146 patients were randomized to receive standard care or standard care plus coronary computed tomography angiography (CCTA).

Objectives

The purpose of this study was to explore the consequences of CCTA-assisted diagnosis on invasive coronary angiography, preventive treatments, and clinical outcomes.

Methods

In post hoc analyses, we assessed changes in invasive coronary angiography, preventive treatments, and clinical outcomes using national electronic health records.

Results

Despite similar overall rates (409 vs. 401; p = 0.451), invasive angiography was less likely to demonstrate normal coronary arteries (20 vs. 56; hazard ratios [HRs]: 0.39 [95% confidence interval (CI): 0.23 to 0.68]; p < 0.001) but more likely to show obstructive coronary artery disease (283 vs. 230; HR: 1.29 [95% CI: 1.08 to 1.55]; p = 0.005) in those allocated to CCTA. More preventive therapies (283 vs. 74; HR: 4.03 [95% CI: 3.12 to 5.20]; p < 0.001) were initiated after CCTA, with each drug commencing at a median of 48 to 52 days after clinic attendance. From the median time for preventive therapy initiation (50 days), fatal and nonfatal myocardial infarction was halved in patients allocated to CCTA compared with those assigned to standard care (17 vs. 34; HR: 0.50 [95% CI: 0.28 to 0.88]; p = 0.020). Cumulative 6-month costs were slightly higher with CCTA: difference $462 (95% CI: $303 to $621).

Conclusions

In patients with suspected angina due to coronary heart disease, CCTA leads to more appropriate use of invasive angiography and alterations in preventive therapies that were associated with a halving of fatal and non-fatal myocardial infarction. (Scottish COmputed Tomography of the HEART Trial [SCOT-HEART]; NCT01149590)

Key Words

angina pectoris
invasive coronary angiography
myocardial infarction
preventive therapy

Abbreviations and Acronyms

CCTA
coronary computed tomography angiography
HR
hazard ratio
IQR
interquartile range
OR
odds ratio

Cited by (0)

This trial was funded by The Chief Scientist Office of the Scottish Government Health and Social Care Directorates (CZH/4/588), with supplementary awards from Edinburgh and Lothian Health Foundation Trust and the Heart Diseases Research Fund. The Royal Bank of Scotland supported the provision of 320-multidetector computed tomography for NHS Lothian and the University of Edinburgh. The Clinical Research Imaging Centre (Edinburgh) is supported by the National Health Service Research Scotland (NRS) through National Health Service Lothian Health Board. The Clinical Research Facility Glasgow and Clinical Research Facility Tayside are supported by NRS. Drs. Williams (FS/11/014) and Newby (CH/09/002) are supported by the British Heart Foundation. Dr. Shah has received speaker fees from Abbott Diagnostics. Dr. Smith is supported by the NIHR Oxford Biomedical Research Centre. Dr. Berry’s institution has research and consultancy agreements with St. Jude Medical and AstraZeneca; and has a research agreement with Siemens Healthcare. Dr. Flather has received speaker fees from AstraZeneca; has served on the advisory board of AstraZeneca and Novartis; and has received grants from Novartis. Drs. Roditi, van Beek, and Newby have received honoraria and consultancy from Toshiba Medical Systems. Dr. Roditi has received honoraria from companies producing contrast media, such as Bracco, Bayer-Schering, GE Healthcare, and Guerbet. Dr. van Beek is supported by the Scottish Imaging Network: A Platform of Scientific Excellence (SINAPSE). Dr. Timmis is supported by Barts Cardiovascular Biomedical Research Unit, funded by the National Institute for Health Research. Dr. Newby is the recipient of a Wellcome Trust Senior Investigator Award (WT103782AIA). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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