英国爱丁堡大学Michelle C Williams团队研究了冠状动脉CT血管造影指导下稳定型胸痛患者治疗对预后的影响。相关论文于2025年1月25日发表在《柳叶刀》杂志上。

苏格兰心脏计算机断层扫描（SCOT-Heart）试验表明，冠状动脉CT血管造影（CCTA）指导下的管理改善了稳定型胸痛患者的诊断、管理和预后。该研究旨在评估CCTA指导下的护理是否会导致管理和预后的持续长期改善。

SCOT-HEART是一项开放标签、多中心、平行组试验，患者来自苏格兰12个门诊心脏病学胸痛诊所。符合条件的患者年龄在18~75岁之间，有疑似冠心病引起的稳定型心绞痛症状。患者被随机分配（1:1）到标准护理加CCTA或单独的标准护理。在这项预先指定的10年分析中，处方数据、冠状动脉手术干预和临床结局通过国家登记处的记录链接获得。主要结局是基于意向治疗的冠心病死亡或非致命性心肌梗死。

2010年11月18日至2014年9月24日，研究组招募了4146名患者（平均年龄57岁[SD 10]，2325名[56.1%]男性，1821名[43.9%]女性），其中2073名患者随机分配到标准护理和CCTA组，2073名仅接受标准护理。中位10年后（IQR 9.3-11.0），与标准护理组相比，CCTA组冠心病死亡或非致死性心肌梗死的发生率较低（137[6.6%]对171[8.2%]；风险比[HR]0.79[95%CI 0.63-0.99]，p=0.044）。

两组之间的全因、心血管和冠心病死亡率以及非致死性卒中的发生率相似（均p>0.05），但CCTA组中非致死性心肌梗死（90[4.3%]对124[6.0%]；HR 0.72[0.55-0.94]，p=0.017）和重大不良心血管事件（172[8.3%]对比214[10.3%]；HR0.80[0.65-0.97]，p=0.026）的发生率较低。冠状动脉血运重建术的发生率相似（315[15.2%]对318[15.3%]；HR 1.00[0.86-1.17]，p=0.99），但CCTA组的预防性治疗处方仍然更频繁（有可用数据的1486名患者中有831[55.9%]对1485名患者中的728[49.0%]；比值比1.17[95%CI 1.01-1.36]，p=0.034）。

研究结果表明，10年后，CCTA指导的稳定型胸痛患者管理与冠心病死亡或非致命性心肌梗死的持续减少有关。通过CCTA识别冠状动脉粥样硬化可以改善稳定型胸痛患者的长期心血管疾病预防。

附：英文原文

Title: Coronary CT angiography-guided management of patients with stable chest pain: 10-year outcomes from the SCOT-HEART randomised controlled trial in Scotland

Author: Michelle C Williams, Ryan Wereski, Christopher Tuck, Philip D Adamson, Anoop S V Shah, Edwin J R van Beek, Giles Roditi, Colin Berry, Nicholas Boon, Marcus Flather, Steff Lewis, John Norrie, Adam D Timmis, Nicholas L Mills, Marc R Dweck, David E Newby, Michelle C Williams, Ryan Wereski, Christopher Tuck, Philip Adamson, Anoop Shah, Edwin JR Van Beek, Giles Roditi, Colin Berry, Nicholas Boon, Marcus Flather, Steff Lewis, John Norrie, Adam D Timmis, Nicholas L Mills, Marc R Dweck, David E Newby, Amanda Hunter, Tania Pawade, Andrew Flapan, John Forbes, Allister Hargreaves, Stephen Leslie, Graham Mckillop, Scott McLean, John Reid, James Spratt, Neal Uren, Liz Clark, Peter Craig, Tom Barlow, Chiara McCormack, Susan Shepherd, Marise Bucukoglu, Valentina Assi, Richard Parker, Ashma Krishan, Fiona Wee, Anthony Wackett, Allan Walker, Lynsey Milne, Kat Oatey, Paul Neary, Gillian Donaldson, Terry Fairbairn, Marlene Fotheringham, Fiona Hall, Stephen Glen, Sarah Perkins, Fiona Taylor, Louiza Cram, Catherine Beveridge, Avril Cairns, Frances Dougherty, Hany Eteiba, Alan Rae, Kate Robb, Wenda Crawford, Patricia Clarkin, Elizabeth Lennon, Graeme Houston, Stuart Pringle, Prasad Gunter Ramkumar, Thiru Sudarshan, Yvonne Fogarty, Dawn Barrie, Kim Bissett, Adelle Dawson, Scott Dundas, Deborah Letham, Linda ONeill, Valerie Ritchie, Jonathan Weir-McCall, Hamish Dougall, Faheem Ahmed, Alistair Cormack, Iain Findlay, Stuart Hood, Clare Murphy, Eileen Peat, Lynne McCabe, Margaret McCubbin, Barbara Allen, Miles Behan, Danielle Bertram, David Brian, Amy Cowan, Nicholas Cruden, Martin Denver, Laura Flint, Samantha Fyfe, Neil Grubb, Collette Keanie, Chris Lang, Tom MacGillivray, David MacLachlan, Margaret MacLeod, Saeed Mirsadraee, Avril Morrison, David Northridge, Alyson Phillips, Laura Queripel, Nicholas Weir, Ashok Jacob, Fiona Bett, Frances Divers, Katie Fairley, Edith Keegan, Tricia White, Julia Fowler, John Gemmill, James McGowan, Margo Henry

Issue&Volume: 2025/01/25

Abstract:

Background

The Scottish Computed Tomography of the Heart (SCOT-HEART) trial demonstrated that management guided by coronary CT angiography (CCTA) improved the diagnosis, management, and outcome of patients with stable chest pain. We aimed to assess whether CCTA-guided care results in sustained long-term improvements in management and outcomes.

Methods

SCOT-HEART was an open-label, multicentre, parallel group trial for which patients were recruited from 12 outpatient cardiology chest pain clinics across Scotland. Eligible patients were aged 18–75 years with symptoms of suspected stable angina due to coronary heart disease. Patients were randomly assigned (1:1) to standard of care plus CCTA or standard of care alone. In this prespecified 10-year analysis, prescribing data, coronary procedural interventions, and clinical outcomes were obtained through record linkage from national registries. The primary outcome was coronary heart disease death or non-fatal myocardial infarction on an intention-to-treat basis. This trial is registered at ClinicalTrials.gov (NCT01149590) and is complete.

Findings

Between Nov 18, 2010, and Sept 24, 2014, 4146 patients were recruited (mean age 57 years [SD 10], 2325 [56·1%] male, 1821 [43·9%] female), with 2073 randomly assigned to standard care and CCTA and 2073 to standard care alone. After a median of 10·0 years (IQR 9·3–11·0), coronary heart disease death or non-fatal myocardial infarction was less frequent in the CCTA group compared with the standard care group (137 [6·6%] vs 171 [8·2%]; hazard ratio [HR] 0·79 [95% CI 0·63–0·99], p=0·044). Rates of all-cause, cardiovascular, and coronary heart disease death, and non-fatal stroke, were similar between the groups (p>0·05 for all), but non-fatal myocardial infarctions (90 [4·3%] vs 124 [6·0%]; HR 0·72 [0·55–0·94], p=0·017) and major adverse cardiovascular events (172 [8·3%] vs 214 [10·3%]; HR 0·80 [0·65–0·97], p=0·026) were less frequent in the CCTA group. Rates of coronary revascularisation procedures were similar (315 [15·2%] vs 318 [15·3%]; HR 1·00 [0·86–1·17], p=0·99) but preventive therapy prescribing remained more frequent in the CCTA group (831 [55·9%] of 1486 vs 728 [49·0%] of 1485 patients with available data; odds ratio 1·17 [95% CI 1·01–1·36], p=0·034).

Interpretation

After 10 years, CCTA-guided management of patients with stable chest pain was associated with a sustained reduction in coronary heart disease death or non-fatal myocardial infarction. Identification of coronary atherosclerosis by CCTA improves long-term cardiovascular disease prevention in patients with stable chest pain.

DOI: 10.1016/S0140-6736(24)02679-5

Source:https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)02679-5/abstract