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Original Investigation
June 3, 2020

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

Author Affiliations
  • 1British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
  • 2Division of Cardiovascular Medicine, University of Virginia, Charlottesville
  • 3Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
JAMA Cardiol. Published online June 3, 2020. doi:10.1001/jamacardio.2020.1567
Key Points

Question  What is the benefit of exercise electrocardiography in contemporary clinical practice?

Findings  This post hoc analysis of a randomized clinical trial found that abnormal results of exercise electrocardiography were associated with a 14.47-fold increase in coronary revascularization and a 2.57-fold increase in mortality from coronary heart disease at 5 years or in cases of nonfatal myocardial infarction at 5 years. When combined with exercise electrocardiography, coronary computed tomography angiography had a stronger association with 5-year coronary events compared with exercise electrocardiography alone.

Meaning  Although abnormal results of exercise electrocardiography are associated with coronary revascularization and future risk of adverse coronary events, coronary computed tomography angiography may identify additional undetected coronary artery disease and add to clinical decision-making and may be more strongly associated with future risk.

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 (6 of 283 [2%] vs 18 of 283 [6%]), 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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