139 Clinical outcomes of patients excluded from cardiac investigation in the NICE guidelines for chest pain of recent onset

Knowledge on the sequelae of Coronavirus Disease 2019 (COVID-19) remains limited due to the relatively recent onset of this pathology. However, the literature on other types of coronavirus infections prior to COVID-19 reports that patients may experience persistent symptoms after discharge. To determine the prevalence of respiratory symptoms in survivors of hospital admission after COVID-19 infection. A living systematic review of five databases was performed in order to identify studies which reported the persistence of respiratory symptoms in COVID-19 patients after discharge. Two independent researchers reviewed and analysed the available literature, and then extracted and assessed the quality of those articles. Of the 1,154 reports returned by the initial search nine articles were found, in which 1,816 patients were included in the data synthesis. In the pooled analysis, we found a prevalence of 0.52 (CI 0.38–0.66, p < 0.01, I 2 = 97%), 0.37 (CI 0.28–0.48, p < 0.01, I 2 = 93%), 0.16 (CI 0.10–0.23, p < 0.01, I 2 = 90%) and 0.14 (CI 0.06–0.24, p < 0.01, I 2 = 96%) for fatigue, dyspnoea, chest pain, and cough, respectively. Fatigue, dyspnoea, chest pain, and cough were the most prevalent respiratory symptoms found in 52%, 37%, 16% and 14% of patients between 3 weeks and 3 months, after discharge in survivors of hospital admission by COVID-19, respectively.

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

European Heart Journal ◽

10.1093/ehjci/ehaa946.3547 ◽

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

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

Open Heart ◽

10.1136/openhrt-2021-001597 ◽

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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