Key result
Post-2019 ESC guideline-directed management after CCTA is linked to ~1-point lower MACE rates.
Why the study?
The 2019 ESC guidelines changed recommendations for initiating optimal medical therapy after CCTA findings of plaques with or without obstructive stenosis, and whether medical compliance and mid-term outcomes subsequently changed was unknown.
Does management after the 2019 ESC guidelines improve cardiovascular medication compliance and reduce major adverse cardiovascular events in patients undergoing coronary computed tomography angiography?
Cohort (n=17,308)
Yes
Does management after the 2019 ESC guidelines improve cardiovascular medication compliance and reduce major adverse cardiovascular events in patients undergoing coronary computed tomography angiography?
Following the 2019 ESC chronic coronary syndrome guidelines, patients in Sweden undergoing CCTA had increased initial cardiovascular medication prescriptions and a significantly lower rate of MACE (10.9% vs 12.1%, p=0.01), although mid-term drug compliance declined, particularly among those with obstructive stenosis.
Post-guideline CCTA management was associated with modestly lower MACE; supports observational extension of 2019 ESC recommendations but leaves causal benefit open.
Background In 2019, the European Society of Cardiology changed the guidelines regarding initiation of optimal medical therapy in the presence of cardiovascular disease e.g. after coronary computed tomography angiography (CCTA)[1] and findings of plaques with or without obstructive stenosis. Purpose This study aims to investigate if medical treatment changed post guidelines regarding medical compliance and the mid-term effects on outcome. Method This project collated data from the national quality registry SWEDEHEART[2], and from the Drug, Death and Specialized Care Registry, including nationwide data from CCTA in Sweden, retrieved cardiovascular prescriptions, visits to specialized care and data/causes of death. Patients with CCTA in 2017–2018 (PRE-guidelines) and 2020–2021 (POST) with clinically indicated contrast-enhanced CCTA and/or non-contrast calcium score (CACS) were included. Analysis was stratified by stenosis severity (0: No stenosis; 1: <50%; 2: ≥50%), and Calcium score (CACS 0; 1–99; 100+). Drug change was defined as the difference in unique subclasses before CCTA to directly after CCTA or directly after to mid-term (after 2–3 years). Primary endpoint (MACE) was infarction, unstable angina, cardiovascular death post-CCTA or revascularization more than 6 months after CCTA. Follow-up time was 2 years 11 months. Results 17,308 patients were included, of which 5068 PRE and 12240 POST guidelines. 17,269 had CCTA and 6,409 CACS. Patients in the POST group had more cardiovascular drugs directly after CCTA than PRE, except in patients with stenosis <50% where it was similar (Table 1). The POST group had more lipid lowering drugs than PRE directly after CCTA and at mid term. Drug changes before and directly after CCTA, and after CCTA to mid-term were overall similar between groups. While lipid lowering drugs were similar at mid-term, antihypertensives and anticoagulants decreased (Figure 1). The greater the stenosis severity the higher proportion of drugs were removed in both PRE and POST groups at mid-term. MACE occurred in 1,945 patients, of which 615 (12.1%) in the PRE group and 1330 (10.9%) in POST (p=0.01). In POST time to MACE increased by 1.8% (p=0.02) for stenosis severity 1. For CACS, no difference in MACE between PRE and POST was significant. Conclusion After the 2019 ESC guidelines on chronic coronary syndrome, cardiovascular drug compliance increased on a national level in patients investigated with CCTA in Sweden. However, lipid lowering drugs were largely unchanged at mid-term. The decrease in antihypertensives and anticoagulants at mid-term indicates lower drug compliance 2-3 years after CCTA. Disadvantageously, the drug compliance decreased the most in patients with obstructive stenosis (>50%). Still, the POST guidelines group appears to have fewer events, especially in patients with any type of stenosis. This emphasizes the importance of prescription compliance of optimal medical therapy.
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Johansson et al. (2026) conducted a cohort in Suspected or chronic coronary syndrome investigated with coronary computed tomography angiography (n=17,308). Post-2019 ESC chronic coronary syndrome guidelines management (2020–2021) vs. Pre-2019 ESC guidelines management (2017–2018) was evaluated on Major adverse cardiovascular events (MACE: infarction, unstable angina, cardiovascular death post-CCTA, or revascularization >6 months after CCTA) (p=0.01). Post-2019 ESC guidelines management after CCTA was associated with lower MACE rates compared to pre-guidelines management (10.9% vs 12.1%, p=0.01).
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