RT Journal Article
SR Electronic
T1 Diagnostic and prognostic benefits of computed tomography coronary angiography using the 2016 National Institute for Health and Care Excellence guidance within a randomised trial
JF Heart
JO Heart
FD BMJ Publishing Group Ltd and British Cardiovascular Society
SP 207
OP 214
DO 10.1136/heartjnl-2017-311508
VO 104
IS 3
A1 Adamson, Philip D
A1 Hunter, Amanda
A1 Williams, Michelle C
A1 Shah, Anoop S V
A1 McAllister, David A
A1 Pawade, Tania A
A1 Dweck, Marc R
A1 Mills, Nicholas L
A1 Berry, Colin
A1 Boon, Nicholas A
A1 Clark, Elizabeth
A1 Flather, Marcus
A1 Forbes, John
A1 McLean, Scott
A1 Roditi, Giles
A1 van Beek, Edwin J R
A1 Timmis, Adam D
A1 Newby, David E
YR 2018
UL http://heart.bmj.com/content/104/3/207.abstract
AB 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.