04 May 17. Winners - BMJ award

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The Scottish COmputed Tomography of the HEART(SCOT-HEART) Randomised Controlled Trial demonstrated that, compared to patients randomised to standard care alone, Computed Tomography Coronary Angiography (CTCA):

• changed the diagnosis in 1/4 of patients
• altered investigations in 1/6 of patients, &
• triggered treatment changes in 1/4 of patients

This led to:

• ~3-fold reduction in use of normal, invasive angiography
• more targeted preventative therapies & coronary revascularisation, & 
• halving rates of coronary heart disease deaths & non-fatal myocardial infarction

Patients reported:

• excellent levels of satisfaction
• improved quality of life in both those with normal coronary arteries & those with severe disease

The trial was published in The Lancet in 2015 with numerous further publications.

The trial is widely viewed as demonstrating the efficacy of CTCA in managing patients with suspected angina pectoris & is a flag ship of how efficient & effective trials can be conducted within the NHS service.

The Scot-Heart trial has transformed how we manage patients with suspected angina pectoris due to coronary heart disease. Computed tomography coronary angiography (CTCA) is now the first line investigation of choice for the NHS.

Professor David Newby

Background

The problem:

• coronary heart disease is the commonest cause of death across the world
• 2.3 million people in the UK are affected
• angina pectoris is the commonest manifestation
• angina pectoris is challenging to diagnose because it is one of a wide range of causes of chest pain
• non-invasive diagnostic tests for chest pain are inconsistent - practices & international guidelines vary widely
• there is a a poor evidence base for the diagnostic test selection

Preliminary work:

The team which eventually became SCOT-HEART:

• conducted a comprehensive literature review around this problem
• identified the potential superior performance of Computed Tomography Coronary Angiography (CTCA)
• discovered that that further research was required
• in the team's region, there was no established CTCA service
• the benefits of CTCA over existing practices were unclear

Establishing a research centre:

• a multidisciplinary team created a new imaging centre (Clinical Research Imaging Centre - CRIC) in 2009
• funded by:
  • British Heart Foundation
  • Medical Research Council
  • Wellcome Trust
  • University of Edinburgh
  • NHS Lothian

NHS Lothian & the University of Edinburgh together developed our CTCA service with involvement of patients & clinicians, which is now mature & established.

This required extensive training and dedication to improve image quality whilst reducing radiation exposure.

The research environment and the attention to detail has led to extremely low radiation doses for CTCA (2-3 mSv), which is 5-fold lower than comparable institutions in North American (~10 mSv).

Setting up a trial

We designed a major multicentre, Scotland-wide, randomised controlled clinical trial to determine the effect of CTCA on diagnosis, investigation, management & ultimate clinical outcome of patients with suspected angina pectoris due to coronary heart disease (the SCOT-HEART trial).

This was funded by the Chief Scientist’s Office of the Scottish Government.

We involved clinicians in secondary care across Scotland in the design, conduct & delivery of our trial, guided by patient representatives & research funders.

We randomised 4,146 patients with suspected angina pectoris due to coronary heart disease (~40% of patients attending the clinics) from 12 Cardiology Rapid Access Chest Pain Clinics across Scotland, to standard care or standard care with CTCA.

Outcomes

The SCOT-HEART trial distinguished itself by its broad inclusive & generalisable study population, as well as its implementation in routine real-world clinical practice with patient-centred & clinician-centred outcomes.

The SCOT-HEART team has widely shared its clinical & research experience, having established training programmes, clinical CTCA courses & presentations at national & international meetings.

The trial has already led to changes in NICE guidance (CG95; November 2016 Update), which states that this is an extremely cost effective strategy.