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Randomized Controlled Trial
. 2020 Aug 1;5(8):920-928.
doi: 10.1001/jamacardio.2020.1567.

Exercise Electrocardiography and Computed Tomography Coronary Angiography for Patients With Suspected Stable Angina Pectoris: A Post Hoc Analysis of the Randomized SCOT-HEART Trial

Trisha Singh  1 , Rong Bing  1 , Marc R Dweck  1 , Edwin J R van Beek  1 , Nicholas L Mills  1 , Michelle C Williams  1 , Todd C Villines  2 , David E Newby  1 , Philip D Adamson  1   3
Affiliations
Randomized Controlled Trial

Exercise Electrocardiography and Computed Tomography Coronary Angiography for Patients With Suspected Stable Angina Pectoris: A Post Hoc Analysis of the Randomized SCOT-HEART Trial

Trisha Singh et al. JAMA Cardiol. .

Erratum in

Abstract

Importance: Recent European guidance supports a diminished role for exercise electrocardiography (ECG) in the assessment of suspected stable angina.

Objective: To evaluate the utility of exercise ECG in contemporary practice and assess the value of combined functional and anatomical testing.

Design, setting, and participants: This is a post hoc analysis of the Scottish Computed Tomography of the Heart (SCOT-HEART) open-label randomized clinical trial, conducted in 12 cardiology chest pain clinics across Scotland for patients with suspected angina secondary to coronary heart disease. Between November 18, 2010, and September 24, 2014, 4146 patients aged 18 to 75 years with stable angina underwent clinical evaluation and 1417 of 1651 (86%) underwent exercise ECG prior to randomization. Statistical analysis was conducted from October 10 to November 5, 2019.

Interventions: Patients were randomized in a 1:1 ratio to receive standard care plus coronary computed tomography (CT) angiography or to receive standard care alone. The present analysis was limited to the 3283 patients who underwent exercise ECG alone or in combination with coronary CT angiography.

Main outcomes and measures: The primary clinical end point was death from coronary heart disease or nonfatal myocardial infarction at 5 years.

Results: Among the 3283 patients (1889 men; median age, 57.0 years [interquartile range, 50.0-64.0 years]), exercise ECG had a sensitivity of 39% and a specificity of 91% for detecting any obstructive coronary artery disease in those who underwent subsequent invasive angiography. Abnormal results of exercise ECG were associated with a 14.47-fold (95% CI, 10.00-20.41; P < .001) increase in coronary revascularization at 1 year and a 2.57-fold (95% CI, 1.38-4.63; P < .001) increase in mortality from coronary heart disease death at 5 years or in cases of nonfatal myocardial infarction at 5 years. Compared with exercise ECG alone, results of coronary CT angiography had a stronger association with 5-year coronary heart disease death or nonfatal myocardial infarction (hazard ratio, 10.63; 95% CI, 2.32-48.70; P = .002). The greatest numerical difference in outcome with CT angiography compared with exercise ECG alone was observed for those with inconclusive results of exercise ECG (5 of 285 [2%] vs 13 of 283 [5%]), although this was not statistically significant (log-rank P = .05).

Conclusions and relevance: This study suggests that abnormal results of exercise ECG are associated with coronary revascularization and the future risk of adverse coronary events. However, coronary CT angiography more accurately detects coronary artery disease and is more strongly associated with future risk compared with exercise ECG.

Trial registration: ClinicalTrials.gov Identifier: NCT01149590.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr van Beek reported receiving grants from the Chief Scientist Office, Scotland, during the conduct of the study; personal fees from Aidence and Mentholatum; nonfinancial support from Imbio and Siemens Healthineers; and being the founder of Quantitative Clinical Trials Imaging Services, Inc, outside the submitted work. Dr Mills reported that The University of Edinburgh has received research grants from Abbott Diagnostics and Siemens Healthineers; in addition, Dr Mills reported receiving honoraria from Abbott Diagnostics, Siemens Healthineers, and Roche Diagnostics. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. CONSORT Diagram: Study Population
CTCA indicates computed tomography coronary angiography; ECG, electrocardiography; and SCOT-HEART, Scottish Computed Tomography of the Heart.
Figure 2.
Figure 2.. Cumulative Incidence of Coronary Revascularization
A, At 1 year stratified by exercise electrocardiography (ECG) outcome (normal, inconclusive, and abnormal) and trial allocation (standard of care and standard of care plus computed tomography coronary angiography (CTCA). B, At 1 year for combined inconclusive and normal exercise electrocardiography stratified by study group (standard of care [standard] and standard of care plus CTCA).
Figure 3.
Figure 3.. Cumulative Incidence of Coronary Heart Disease Death or Nonfatal Myocardial Infarction
A, Stratified by exercise electrocardiography (ECG) outcome (normal, inconclusive, and abnormal). B, Stratified by computed tomography coronary angiography (CTCA) outcome (normal, nonobstructive, and obstructive).
Figure 4.
Figure 4.. Cumulative Incidence of Coronary Heart Disease Death or Nonfatal Myocardial Infarction
A, Patients with abnormal electrocardiography (ECG) results by treatment allocation (standard of care [standard] and standard of care plus computed tomography coronary angiography [CTCA]. B, Patients with inconclusive ECG results by treatment allocation. C, Patients with normal ECG results by treatment allocation.
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References

    1. Sekhri N, Perel P, Clayton T, Feder GS, Hemingway H, Timmis A. A 10-year prognostic model for patients with suspected angina attending a chest pain clinic. Heart. 2016;102(11):869-875. doi:10.1136/heartjnl-2015-308994 - DOI - PMC - PubMed
    1. Blankstein R, Ahmed W, Bamberg F, et al. . Comparison of exercise treadmill testing with cardiac computed tomography angiography among patients presenting to the emergency room with chest pain: the Rule Out Myocardial Infarction Using Computer-Assisted Tomography (ROMICAT) study. Circ Cardiovasc Imaging. 2012;5(2):233-242. doi:10.1161/CIRCIMAGING.111.969568 - DOI - PubMed
    1. Gibbons RJ, Balady GJ, Bricker JT, et al. ; American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines) . ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation. 2002;106(14):1883-1892. doi:10.1161/01.CIR.0000034670.06526.15 - DOI - PubMed
    1. Mark DB, Hlatky MA, Harrell FE Jr, Lee KL, Califf RM, Pryor DB. Exercise treadmill score for predicting prognosis in coronary artery disease. Ann Intern Med. 1987;106(6):793-800. doi:10.7326/0003-4819-106-6-793 - DOI - PubMed
    1. Zohn DH. Guidelines for Exercise Testing and Prescription. Arch Phys Med Rehabil. 1986;67(8):P519.

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