Author + information
- Paul C. Cremer, MD and
- Wael A. Jaber, MD∗ ()
- ↵∗Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue: Desk J1, Cleveland, Ohio 44195
We read with interest the most recent publication from the SCOT-HEART (Scottish COmputed Tomography of the HEART) investigators that raised the prospect of using coronary computed tomographic angiography (CCTA) results to guide medical therapy (1). Even though it is difficult to make definitive conclusions from a post hoc analysis of a secondary endpoint, especially with so few events, testing this hypothesis seems most reasonable in patients who are already on optimal medical therapy based upon their clinical risk. Specifically, can CCTA results, when obtained in symptomatic patients, facilitate enhanced medical therapy?
In this context, further data from the SCOT-HEART investigators would be useful. For example, of the 226 patients started on a statin after CCTA, how many should have been on a statin on the basis of global cardiovascular risk? As noted in the supplement, 51 of 335 patients with obstructive CAD on CCTA were started on a statin. In the remaining 85% of patients, how many were already on a statin, had demonstrated statin intolerance, or did not need a statin on the basis of global cardiovascular risk?
In the SCOT-HEART trial, 10-year coronary heart disease (CHD) risk was assessed with the ASSIGN score (2). In general, patients with CCTA had an intermediate-to-high 10-year CHD risk (18 ± 11%), but only 44% were on a statin (3). Similarly, in the 233 patients with revascularization following CCTA, what was the background medical therapy? Revascularization appears to have followed the oculostenotic reflex. In the current era, revascularization is most appropriate for stable patients that remain symptomatic despite optimal medical therapy.
In conclusion, the SCOT-HEART investigators should be congratulated for running a large pragmatic trial. By design, therapy was not mandated. Nonetheless, optimizing current use of primary prevention risk calculators is a necessary first step before the promise of enhanced medical therapy with CCTA can be evaluated.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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