The SCOT-HEART trial: cardiac CT to guide patient management and improve outcomes.
The SCOT-HEART trial: cardiac CT to guide patient management and improve outcomes.
复制标题
SCOT-HEART 试验：心脏 CT 指导患者管理并改善结果。
DOI：
10.1093/cvr/cvz173
复制
发表时间：
2019
影响因子：
10.8
通讯作者：
Nazir MS
中科院分区：
文献类型：
--
作者：
Nazir MS
在过去的十年中，冠状动脉计算机断层扫描血管造影术（CCTA）作为冠状动脉疾病（CAD）的诊断工具取得了一些技术进步。CCTA可用于识别冠状动脉的解剖学疾病，并已被证明具有极好的阴性预测值1，正常CCTA与0.28%的年死亡率相关。2尽管之前的国际指南推荐CCTA用于低风险胸痛患者，3但最近的NICE指南现在推荐CCTA作为无已知CAD患者心绞痛胸痛的一线研究。4 SCOT-HEART试验的结果可能会提供证据，推动CCTA在CAD评估中的作用。在发表在《柳叶刀》上的SCOTHEART试验中，4146例稳定型心绞痛患者被随机分配至单独标准治疗组和标准治疗加CCTA组。5研究的主要终点是6周时继发于冠心病的心绞痛诊断的确定性。CCTA组中23%的患者诊断发生变化，而标准治疗组为1%。经过1.7年的随访，CCTA与致死性和非致死性心肌梗死（MI）减少38%相关，尽管这并不显著[风险比（HR）0.62，95%置信区间（CI）0.38-1.01; P= 0.0527]。5然而，在一项具有里程碑意义的事后分析中，使用50天的中位时间来允许治疗改变，CCTA组的致死性和非致死性MI在统计学上显著减少了50%（HR 0.50，95% CI 0.28-0.88; P= 0.020）。6 SCOT-HEART试验的5年随访显示CCTA对临床结局的影响更大。在一项对SCOT-HEART试验参与者进行的为期4.8年的中位随访研究中，与标准治疗组相比，CCTA组中冠心病或非致死性MI死亡的主要临床终点显著降低了41%（2.3% vs. 3.9%，P= 0.004）（图1a）。7这种获益主要是由于非致死性MI的减少（图1b）。有几个看似合理的原因可以解释这种减少。最值得注意的是，与标准治疗组相比，CCTA组中开始使用预防性和抗心绞痛药物的患者比例更大。然而，需要承认的一个重要局限性是，两组未设盲，这可能导致临床医生治疗的固有偏倚。然而，这些显著的发现是一个很好的例子，其中心血管成像的应用已被证明可以改变临床管理和结果。
The past decade has seen several technical advances in coronary computed tomography angiography (CCTA) as a diagnostic tool for coronary artery disease (CAD). CCTA can be used to identify anatomical disease of the coronary arteries and has been shown to have an excellent negative predictive value 1 and a normal CCTA is associated with an annualized death rate of 0.28%. 2 Whereas previous international guidelines have recommended CCTA for low-risk chest pain patients, 3 recent NICE guidelines now recommend CCTA as first line for investigation of anginal chest pain in patients without known CAD. 4 The findings of the SCOT-HEART trial are likely to provide evidence that will propel the role of CCTA for CAD assessment. In the SCOTHEART trial published in the Lancet, 4146 patients with stable angina were randomized to standard care alone and standard care with addition of CCTA. 5 The primary endpoint of the study was the certainty of diagnosis of angina secondary to coronary heart disease at 6 weeks. The diagnosis was changed in 23% of patients in the CCTA group compared with 1% in the standard care group. After a 1.7-year follow-up period, CCTA was associated with a 38% reduction in fatal and non-fatal myocardial infarction (MI), although this was not significant [hazard ratio (HR) 0.62, 95% confidence interval (CI) 0.38–1.01; P= 0.0527]. 5 However, in a landmark post hoc analysis, using a median time of 50 days to allow for treatment alteration, there was a statistically significant 50% reduction in fatal and non-fatal MI in the CCTA group (HR 0.50, 95% CI 0.28–0.88; P= 0.020). 6The 5-year follow-up to the SCOT-HEART trial has generated even greater impact of CCTA on clinical outcomes. In a 4.8-year median follow-up study of the participants of the SCOT-HEART trial, there was a 41% significant reduction in the primary clinical endpoint of death from coronary heart disease or nonfatal MI in the CCTA group compared with the standard care group (2.3% vs. 3.9%, P= 0.004)(Figure 1a). 7 This benefit was primarily driven by a reduction in non-fatal MI (Figure 1b). There are several plausible reasons that may explain this reduction. Most notably, there were a greater proportion of patients in the CCTA group that were initiated on preventative and antianginal medications compared with the standard care group. However, an important limitation to acknowledge is that there was no blinding of the two groups which may have led to inherent bias of the treatment by the clinicians. Nevertheless, these remarkable findings are an excellent example in which the application of cardiovascular imaging has been demonstrated to change clinical management and outcomes.
影响因子：
24
作者：
Williams MC;Hunter A;Shah ASV;Assi V;Lewis S;Smith J;Berry C;Boon NA;Clark E;Flather M;Forbes J;McLean S;Roditi G;van Beek EJR;Timmis AD;Newby DE;SCOT-HEART Investigators
通讯作者：
SCOT-HEART Investigators