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Comment & Response
July 3, 2019

Coronary Computed Tomography Angiography as the Investigation of Choice for Stable Chest Pain

Author Affiliations
  • 1NewYork–Presbyterian Hospital, Weill Cornell Medical College, New York
  • 2University of Edinburgh, Edinburgh, Scotland
JAMA Cardiol. 2019;4(9):948. doi:10.1001/jamacardio.2019.2071

To the Editor We read with interest the Viewpoint by Kaul1 on the use of coronary computed tomography angiography (CCTA) for patients with stable chest pain. He provides largely statistical arguments for why he believes the 41% reduction in myocardial infarction at 5 years observed for patients randomized to CCTA-guided care in the Scottish Computed Tomography of the Heart (SCOT-HEART) trial2 is implausible. He suggested that the SCOT-HEART trial had “serious design limitations”1 as a trial of functional testing vs functional plus anatomic testing. This design reflected a direct comparison of a CCTA-guided strategy vs the standard of care in the United Kingdom. This is reflective of the preponderance of cardiology care globally and confers widespread generalizability. Kaul1 concedes that a CCTA-guided strategy improves diagnostic certainty with higher rates of appropriate alterations to angiography, revascularization, and preventive therapies. However, he questions the ability of a diagnostic test to influence outcomes to the degree observed in the SCOT-HEART trial2 but bases this on incorrect values. For example, as previously reported,2 the number needed to be referred for a CCTA to prevent a myocardial infarction is not 250 but 63, and the differences in preventative therapy prescribing are more than twice those he reports. Further, the 41% reduction in myocardial infarction at 5 years is a point estimate, and the 95% CIs range from 16% to 59%, which is consistent with all trials, meta-analyses, and registries to date, to our knowledge.2,3

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