Objectives To evaluate the diagnostic and prognostic benefits of CT coronary angiography (CTCA) using the 2016 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) trial of 4146 participants with suspected angina randomised to CTCA. Patients were dichotomised into NICE guideline-defined possible angina and non-anginal presentations. Primary (diagnostic) endpoint was diagnostic certainty of angina at 6 weeks and prognostic endpoint comprised fatal and non-fatal myocardial infarction (MI).
Results In 3770 eligible participants, CTCA increased diagnostic certainty more in those with possible angina (relative risk (RR) 2.22 (95% CI 1.91 to 2.60), p<0.001) than those with non-anginal symptoms (RR 1.30 (1.11 to 1.53), p=0.002; pinteraction <0.001). In the possible angina cohort, CTCA did not change rates of invasive angiography (p=0.481) but markedly reduced rates of normal coronary angiography (HR 0.32 (0.19 to 0.52), p<0.001). In the non-anginal cohort, rates of invasive angiography increased (HR 1.82 (1.13 to 2.92), p=0.014) without reducing rates of normal coronary angiography (HR 0.78 (0.30 to 2.05), p=0.622). At 3.2 years of follow-up, fatal or non-fatal MI was reduced in patients with possible angina (3.2% to 1.9%%; HR 0.58 (0.34 to 0.99), p=0.045) but not in those with non-anginal symptoms (HR 0.65 (0.25 to 1.69), p=0.379).
Conclusions NICE-guided patient selection maximises the benefits of CTCA on diagnostic certainty, use of invasive coronary angiography and reductions in fatal and non-fatal myocardial infarction. Patients with non-anginal chest pain derive minimal benefit from CTCA and increase the rates of invasive investigation.
Trial registration number ClinicalTrials.gov: NCT01149590;post results.
- Cardiac computer tomographic (CT) imaging
- Coronary artery disease
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PDA and AH contributed equally.
Contributors PDA, AH, MCW, MRD, DAM and DEN contributed to the conception and design of this work. PDA, AH, MCW, ASVS, TAP, MRD, CB, NAB, MF, JF, SM, GR, EJRvB, ADT and DEN contributed to the acquisition of study data. PDA, AH, MCW, MRD, ASVS, DAM and DEN contributed to the analysis and interpretation of data and drafting of the manuscript. PDA, AH, MCW, ASVS, DAM, TAP, MRD, NLM, CB, NAB, EC, MF, JF, SM, GR, EJRvB, ADT and DEN contributed to the revision of the manuscript. PDA and DEN are responsible for the overall content of this work. The SCOT-HEART Investigators contributed to the conception or design of the work, or the acquisition, analysis or interpretation of data for the work. They were involved in drafting the manuscript and revising it and have given final approval of the version to be published. The SCOT-HEART investigators are accountable for the work.
Competing interests DEN, EJRvB and GR have received honoraria and consultancy from Toshiba Medical Systems. GR has received honoraria from companies (Bracco, Bayer-Schering, GE Healthcare and Guerbet) producing contrast media.
Patient consent Obtained.
Ethics approval South East Scotland Research Ethics Committee.
Provenance and peer review Not commissioned; externally peer reviewed.