Coronary CTA bests exercise ECG in predicting future events

  • Singh T & al.
  • JAMA Cardiol
  • 08.06.2020

  • von Emily Willingham, PhD
  • Clinical Essentials
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Takeaway

  • Abnormal findings on exercise ECG can predict need for later coronary revascularization and acute coronary event risk in stable angina, but coronary CT angiography (CTA) outperforms it.

Why this matters

  • European guidance has deemphasized exercise ECG for assessing stable angina.
  • Editorial: this post hoc analysis of the SCOT-HEART randomized controlled trial adjusted the original cohort so much that it should be viewed as “essentially an observational study” and expresses several other concerns about the study.
    • The findings suggest that exercise ECG “still has value,” the editorial writer says.

Key results

  • Exercise ECG had 39% sensitivity and 91% specificity for detecting obstructive coronary artery disease (CAD) in patients who later had revascularization.
  • Abnormal exercise ECG findings were linked to:
    • 14.47-fold increased 1-year coronary revascularization (P<.001>
    • 2.57-fold increased coronary heart disease mortality/nonfatal myocardial infarction at 5 years (P<.001>
  • With abnormal coronary CTA vs normal, HRs:
    • For 5-year coronary heart disease mortality/nonfatal myocardial infarction: 10.63 (P=.002).
    • For 5-year nonobstructive CAD: 5.32 (P=.03).
  • Patients who had normal or inclusive exercise ECG findings were likelier to have obstructive disease on CTA (79%) vs patients in standard care (24%).

Study design

  • Original SCOT-HEART involved 12 cardiology chest pain clinics in Scotland, from November 18, 2010 to September 24, 2014.
  • Current analysis included 3283 patients from original trial.
  • Funding: Scottish Government; British Heart Foundation; others.

Limitations

  • Post hoc analysis.
  • Findings are “hypothesis generating,” the authors say.
  • Exercise ECG was not randomized.