Coronary computed tomography versus stress echocardiography-guided management of stable chest pain patients: a propensity matched analysis

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Vamvakidou ◽  
O Danylenko ◽  
J Pradhan ◽  
M Kelshiker ◽  
T Jones ◽  
...  
Keyword(s):  
Chest Pain ◽  
Coronary Angiography ◽  
Stable Angina ◽  
Stress Echocardiography ◽  
Invasive Coronary Angiography ◽  
Real Life ◽  
First Line ◽  
Clinical Value ◽  
Line Test ◽  
Stable Chest Pain

Abstract Background Recent recommendations by national and international societies advocate the use of coronary computed tomography (CCT) as the first-line test for the assessment of low-risk patients with suspected stable angina. However limited real-life data exist regarding its relative clinical value versus stress echocardiography (SE)-guided management. Purpose We aimed to assess in a real-life setting the clinical value of stress echocardiography (SE)-guided versus CCT-guided management in patients presenting with stable chest pain and no prior history of coronary artery disease (CAD). Methods We compared the relative feasibility, efficacy and the proportion of patients undergoing downstream testing including revascularisation and their impact on outcome (mortality and myocardial infarction) when CCT versus SE were used as the first line test for the assessment of stable chest pain. Of the patients who underwent CCT (N=2192) or SE (N=2081) between October 2013 and October 2014 only those with suspected stable angina and without previous CAD were selected. The population was propensity-matched (total 1980 patients-990 patients each group) to account for differences in the baseline cardiovascular risk factors. Results The mean age of the population was 59±13.2 years and 949 (47.9%) patients were male. Inconclusive tests were 6% versus 3% (p<0.005) in CCT versus SE. Severe (>70%) luminal stenosis on CCT and inducible ischemia on SE detected obstructive CAD by invasive coronary angiography in 63% versus 57% patients (p=0.33). Over the entire follow-up period (median 717 (IQR 93–1069) days) significantly more patients underwent invasive coronary angiography (21.5% versus 7.3%, p<0.005) and revascularisation (33.5% versus 3.5%, p<0.005) respectively in the CCT versus the SE group. Following their initial assessment 336 (33.9%) patients in the CCT and 86 (8.7%) in the SE group underwent further functional testing (SE, stress cardiac MRI, exercise electrocardiography) (p<0.005) (Figure 1A). There was no difference in all-cause mortality (p=0.26) or death and myocardial infarction (p=0.16) between the two groups (Figure 1B). Conclusions SE when used for the assessment of patients with stable angina and no prior CAD resulted in more conclusive tests, similar detection of obstructive CAD, less overall invasive coronary angiography and revascularization and less subsequent functional tests compared with CCT. Figure 1 Funding Acknowledgement Type of funding source: None

Relative clinical value of coronary computed tomography and stress echocardiography-guided management of stable chest pain patients: a propensity-matched analysis

2020 ◽  
Author(s):  
Anastasia Vamvakidou ◽  
Oleksandr Danylenko ◽  
Jiwan Pradhan ◽  
Mihir Kelshiker ◽  
Timothy Jones ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Chest Pain ◽  
Coronary Angiography ◽  
Stress Echocardiography ◽  
Invasive Coronary Angiography ◽  
Low Risk ◽  
Clinical Value ◽  
Coronary Computed Tomography ◽  
Stable Chest Pain

Abstract Aims The European Society of Cardiology recommends coronary computed tomography (CCT) for the assessment of low-risk patients with suspected stable angina. We aimed to assess in a real-life setting the relative clinical value of stress echocardiography (SE)- and CCT-guided management in this population. Methods and results Patients with stable chest pain and no prior history of coronary artery disease (CAD) who underwent CCT or SE as the initial investigative strategy were propensity-matched (990 patients each group-age: 59 ± 13.2 years, males: 47.9%) to account for baseline differences in cardiovascular risk factors. Inconclusive tests were 6% vs. 3% (P < 0.005) in CCT vs. SE. Severe (≥70% stenosis) on CCT and inducible ischaemia on SE detected obstructive CAD by invasive coronary angiography in 63% vs. 57% patients (P = 0.33). Over the follow-up period (median 717, interquartile range 93–1069 days) more patients underwent invasive coronary angiography (21.5% vs. 7.3%, P < 0.005), revascularization (7.3% vs. 3.5%, P < 0.005), further functional testing 33.4% vs. 8.7% (P < 0.005), but more patients were prescribed statins 8.8% vs. 3.8% (P < 0.005) in the CCT vs. the SE arm, respectively. Combined all-cause mortality and acute myocardial infarction was low—CCT-2.3% and SE-3.3%—with no significant difference (P = 0.16). Conclusion Initial SE-guided management was similar for the detection of obstructive CAD, demonstrated better resource utilization, but was associated with reduced prescription of statins although with no difference in medium-term outcome compared to CCT in this very low-risk population. However, a randomized study with longer follow-up is needed to confirm the clinical value of our findings.

scholarly journals P1589 Yield of invasive coronary angiography following the UK NICE 2016 guideline expansion of CT coronary angiography

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
S Fyyaz ◽  
J Hudson ◽  
O Olabintan ◽  
A Katsigris ◽  
S David ◽  
...  
Keyword(s):  
Chest Pain ◽  
Coronary Angiography ◽  
Invasive Coronary Angiography ◽  
Ct Coronary Angiography ◽  
High Yield ◽  
First Line ◽  
Severe Stenosis ◽  
Artery Disease ◽  
Stable Chest Pain ◽  
The Uk

Abstract The UK National Institute of Health and Care Excellence (NICE) updated chest pain guidelines in 2016 and recommended CT coronary angiography (CTCA) as the first line investigation for all patients presenting with new stable chest pain and the removal of the pre-test probability risk scoring. There is a concern that using CTCA in populations with higher likelihood of coronary artery disease (CAD), can lead to higher rates of downstream testing with invasive coronary angiography (ICA). We implemented the NICE 2016 guideline and audited the downstream testing after CTCA. We also evaluated the performance of the ESC risk score (ESC RS). Methods We undertook a retrospective search of the radiology database from January 2017 to June 2018. CTCA reported CAD degree of stenosis as normal/minimal stenosis, mild (30-50%), moderate (50-70%), or severe (>70%). Results In total 652 patients underwent CTCA (mean age 55 yrs; 330 male). 92 patients were found to have moderate or severe stenosis. 69 of them were referred directly to ICA, with 63 undergoing ICA and confirming severe CAD in 40 patients, a yield of 63%. 18 patients with moderate stenosis were referred for stress echo (SE) with one positive result. In total 35 patients went on to be revascularised. 62 patients were found to have mild stenosis. The majority of patients (n = 462) had normal/minimal stenosis. There were 36 inconclusive studies. The ESC RS was calculated retrospectively with the following results: 70 patients had an ESC RS <15% and 2 (3%) were found to have moderate stenosis. 427 patients had an ESC RS 15-50%; 17 (4%) had severe stenosis and 32 (8%) moderate stenosis. 149 patients had an ESC RS 50-85%; 17 (11%) were found to have severe stenosis and 23 (15%) moderate stenosis. Lastly 2 patients had an ESC RS >85% and one had moderate stenosis. Conclusions Our results demonstrate that CTCA is an effective first line test for most patients with new stable chest pain as the majority were found to have normal/minimal disease. In the patients that went on to have ICA, CTCA had a relatively high yield of detecting severe CAD (63%). This was achieved with some use of SE as a gatekeeper to ICA, particularly in patients with moderate CTCA stenosis. SE should be used more after CTCA in patients with moderate stenosis, as a gatekeeper to ICA. The ESC RS was predictive of significant CAD but overestimated the likelihood of CAD. Abstract P1589 Figure. Severe CTCA stenosis of the LAD

scholarly journals Sex-based inequalities in contemporary UK hospital management of stable chest pain

Open Heart ◽  
2021 ◽  
Vol 8 (1) ◽  
pp. e001672
Author(s):  
Gareth Morgan-Hughes ◽  
Michelle Claire Williams ◽  
Margaret Loudon ◽  
Carl A Roobottom ◽  
Stelios Iacovides ◽  
...  
Keyword(s):  
Chest Pain ◽  
Coronary Angiography ◽  
Coronary Arteries ◽  
Communication Systems ◽  
Invasive Coronary Angiography ◽  
Normal Coronary Arteries ◽  
Recent Onset ◽  
Computed Tomographic ◽  
Stable Chest Pain ◽  
Computed Tomographic Coronary Angiography

ObjectiveWe surveyed UK practice of National Institute for Health and Care Excellence (NICE) “Recent onset chest pain” guidance (CG95, 2016), stratified by sex. We looked for sex-related differences in referral to computed tomographic coronary angiography (CTCA) and subsequent functional imaging (FI), invasive coronary angiography (ICA) and revascularisation.MethodsThis was a prospective analysis of CTCA practice in 8 UK centres between 2018 and 2020. Coronary artery disease (CAD) was recorded with the CAD-reporting and data system. Local electronic records/archiving/communication systems were used to collect data regarding subsequent FI, ICA and revascularisation.Results2301 women, 2326 men underwent CTCA; women were older (58±11 vs 55±12 years, p<0.001) but more likely to have normal coronary arteries (46% (1047) vs 29% (685); p<0.001) and less likely to have severe stenosis (7% (169) vs 13% (307); p<0.001). FI was used less for 4% (93) women, 5% (108) men; ICA was also used less for women (8% (182) vs 14% (321)), as was revascularisation (4% (83) vs 8% (177), p<0.001 for all), including those with ≥moderate CTCA stenosis undergoing ICA (53% (79) vs 61% (166); p<0.001).ConclusionsWomen referred for a NICE CG95 (2016) CTCA are more likely to have normal coronary arteries and men more likely to have CAD. More men than women will then undergo ICA and revascularisation even after adjustments for CTCA disease severity. Raised awareness of these inequalities may improve contemporary chest pain care.

scholarly journals Challenges in delivering computed tomography coronary angiography as the first-line test for stable chest pain

Heart ◽  
2017 ◽  
Vol 104 (11) ◽  
pp. 921-927 ◽  
Author(s):  
John G Dreisbach ◽  
Edward D Nicol ◽  
Carl A Roobottom ◽  
Simon Padley ◽  
Giles Roditi
Keyword(s):  
Chest Pain ◽  
Coronary Angiography ◽  
Geographical Variation ◽  
Guideline Implementation ◽  
First Line ◽  
Open Label ◽  
Recent Onset ◽  
Parallel Group ◽  
Stable Chest Pain ◽  
The Uk

ObjectiveThe National Institute for Health and Care Excellence (NICE) clinical guidelines ‘chest pain of recent onset: assessment and diagnosis’ (update 2016) state CT coronary angiography (CTCA) should be offered as the first-line investigation for patients with stable chest pain. However, the current provision in the UK is unknown. We aimed to evaluate this and estimate the requirements for full implementation of the guidelines including geographical variation. Ancillary aims included surveying the number of CTCA-capable scanners and accredited practitioners in the UK.MethodsThe number of CTCA scans performed annually was surveyed across the National Health Service (NHS). The number of percutaneous coronary interventions performed for stable angina in the NHS in 2015 was applied to a model based on SCOT-HEART (CTCA in patients with suspected angina due to coronary heart disease: an open-label, parallel-group, multicentre trial) data to estimate the requirement for CTCA, for full guideline implementation. Details of CTCA-capable scanners were obtained from manufacturers and formally accredited practitioner details from professional societies.ResultsAn estimated 42 340 CTCAs are currently performed annually in the UK. We estimate that 350 000 would be required to fully implement the guidelines. 304 CTCA-capable scanners and 198 accredited practitioners were identified. A marked geographical variation between health regions was observed.ConclusionsThis study provides insight into the scale of increase in the provision of CTCA required to fully implement the updated NICE guidelines. A small specialist workforce and limited number of CTCA-capable scanners may present challenges to service expansion.

scholarly journals Real world cost and health outcomes of patients presented with chest pain in England: which is the most cost-effective first-line test?

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Tsiachristas ◽  
H West ◽  
E.K Oikonomou ◽  
B Mihaylova ◽  
N Sabharwall ◽  
...  
Keyword(s):  
Chest Pain ◽  
Health Outcomes ◽  
Diagnostic Tests ◽  
Clinical Presentation ◽  
Cost Effective ◽  
Funding Source ◽  
First Line ◽  
Nice Guidelines ◽  
Exercise Ecg ◽  
Stable Chest Pain

Abstract Background The National Institute for Health and Care Excellence (NICE) updated their guidance for the management of patients with stable chest pain and recommended that all patients undergo computed tomography coronary angiography (CTCA). This update has sparked a great deal of debate, and was followed by upgrade of CTCA into a Class I indication in the recent ESC guidelines. The cost-effectiveness of using CTCA as first line investigation is still unclear. Purpose To describe the current clinical pathway of patients with stable chest pain presented to outpatient clinics, assess the compliance with the updated NICE guideline, and explore the costs and health outcomes of different non-invasive diagnostic tests in real-world clinical setting. Methods We used data of 4,297 patients who attended chest pain clinics in Oxford between 1 January 2014 and 31 July 2018. Data included clinical presentation (e.g. age and previous cardiovascular conditions), diagnostic tests, outpatient visits, hospitalization, and hospital mortality and was compared between 6 alternative first-line diagnostic tests. Multinomial regressions were performed to estimate the probability of receiving each alternative and the associated cost after adjusting for clinical presentation. A decision tree was developed to describe the clinical pathway for each alternative first-line diagnostic in terms of subsequent diagnostic tests and treatments and to estimate the associated costs and life days. Results The proportion of patients who received CTCA as first line diagnostic test increased from 1% in 2014 to 17% in 2018, while the publication of the updated NICE guidelines in 2016 led to a threefold increase in this proportion. CTCA is less likely to be provided as a first-line diagnostic to patients who are younger age, males, smokers, and have angina, PVD, or diabetes. The standardised rate of hospital admission was the lowest in the exercise ECG cohort (0.35 admissions per 1,000 life-days) followed by the CTCA cohort (0.40 admissions per 1,000 life-days) while the latter cohort had the lowest standardised rate of cardiovascular treatment (2.74% per 1,000 life days). Stress echocardiography and MPS were associated with higher costs compared with CTCA, other ECG, and exercise ECG after adjusting for clinical presentation and days of follow-up. CTCA is the pathway most likely to be cost-effective, even compared to exercise ECG, while the other diagnostic alternatives are dominated (i.e. they cost more for less life-days). Conclusions Currently, the updated NICE guidelines for stable chest pain are implemented only to a fifth of the cases in England. Our findings support existing evidence that CTCA is the most-cost effective first-line diagnostic test for this population. Hopefully, this will inform the debate around the implementation of the guidelines and help commissioning and clinical decision processes worldwide. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Institute of Health Research Oxford Biomedical Research Centre

scholarly journals Downstream testing after CT coronary angiography: time for a rethink?

Open Heart ◽  
2021 ◽  
Vol 8 (1) ◽  
pp. e001597
Author(s):  
Gareth Morgan-Hughes ◽  
Michelle Claire Williams ◽  
Margaret Loudon ◽  
Carl A Roobottom ◽  
Alice Veitch ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Chest Pain ◽  
Coronary Artery ◽  
Coronary Angiography ◽  
Communication Systems ◽  
Ct Coronary Angiography ◽  
Second Line ◽  
Recent Onset ◽  
Line Test ◽  
Artery Disease

ObjectiveWe surveyed UK practice and compliance with the National Institute for Health and Care Excellence (NICE) ‘recent-onset chest pain’ guidance (Clinical Guideline 95, 2016) as a service quality initiative. We aimed to evaluate the diagnostic utility and efficacy of CT coronary angiography (CTCA), NICE-guided investigation compliance, invasive coronary angiography (ICA) use and revascularisation.MethodsA prospective analysis was conducted in nine UK centres between January 2018 and March 2020. The reporter decided whether the CTCA was diagnostic. Coronary artery disease was recorded with the Coronary Artery Disease–Reporting and Data System (CAD-RADS). Local electronic records and picture archiving/communication systems were used to collect data regarding functional testing, ICA and revascularisation. Duplication of coronary angiography without revascularisation was taken as a surrogate for ICA overuse.Results5293 patients (mean age, 57±12 years; body mass index, 29±6 kg/m²; 50% men) underwent CTCA, with a 96% diagnostic scan rate. 618 (12%) underwent ICA, of which 48% (298/618) did not receive revascularisation. 3886 (73%) had CAD-RADS 0–2, with 1% (35/3886) undergoing ICA, of which 94% (33/35) received ICA as a second-line test. 547 (10%) had CAD-RADS 3, with 23% (125/547) undergoing ICA, of which 88% (110/125) chose ICA as a second-line test, with 26% (33/125) leading to revascularisation. For 552 (10%) CAD-RADS 4 and 91 (2%) CAD-RADS 5 patients, ICA revascularisation rates were 64% (221/345) and 74% (46/62), respectively.ConclusionsWhile CTCA for recent-onset chest pain assessment has been shown to be a robust test, which negates the need for further investigation in three-quarters of patients, subsequent ICA overuse remains with almost half of these procedures not leading to revascularisation.

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