110 THE FEASIBILITY OF USING CT CORONARY ANGIOGRAPHY IN PATIENTS WITH STABLE CHEST PAIN AND MODERATE TO HIGH PRE-TEST PROBABILITY OF CORONARY 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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CT coronary angiography and exercise ECG in a population with chest pain and low-to-intermediate pre-test likelihood of coronary artery disease

Heart ◽

10.1136/hrt.2009.191361 ◽

2010 ◽

Vol 96 (24) ◽

pp. 1973-1979 ◽

Cited By ~ 23

Author(s):

E. Maffei ◽

S. Seitun ◽

C. Martini ◽

A. Palumbo ◽

G. Tarantini ◽

...

Keyword(s):

Coronary Artery Disease ◽

Chest Pain ◽

Coronary Artery ◽

Coronary Angiography ◽

Ct Coronary Angiography ◽

Exercise Ecg ◽

Artery Disease

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Clinical pre-test probability for obstructive coronary artery disease: insights from the European DISCHARGE pilot study

European Radiology ◽

10.1007/s00330-020-07175-z ◽

2020 ◽

Author(s):

Sarah Feger ◽

Paolo Ibes ◽

Adriane E. Napp ◽

Alexander Lembcke ◽

Michael Laule ◽

...

Keyword(s):

Coronary Artery Disease ◽

Chest Pain ◽

Coronary Artery ◽

Pilot Study ◽

Prediction Models ◽

Obstructive Coronary Artery Disease ◽

Disease Prevalence ◽

Artery Disease ◽

Stable Chest Pain ◽

Test Probability

Abstract Objectives To test the accuracy of clinical pre-test probability (PTP) for prediction of obstructive coronary artery disease (CAD) in a pan-European setting. Methods Patients with suspected CAD and stable chest pain who were clinically referred for invasive coronary angiography (ICA) or computed tomography (CT) were included by clinical sites participating in the pilot study of the European multi-centre DISCHARGE trial. PTP of CAD was determined using the Diamond-Forrester (D+F) prediction model initially introduced in 1979 and the updated D+F model from 2011. Obstructive coronary artery disease (CAD) was defined by one at least 50% diameter coronary stenosis by both CT and ICA. Results In total, 1440 patients (654 female, 786 male) were included at 25 clinical sites from May 2014 until July 2017. Of these patients, 725 underwent CT, while 715 underwent ICA. Both prediction models overestimated the prevalence of obstructive CAD (31.7%, 456 of 1440 patients, PTP: initial D+F 58.9% (28.1–90.6%), updated D+F 47.3% (34.2–59.9%), both p < 0.001), but overestimation of disease prevalence was higher for the initial D+F (p < 0.001). The discriminative ability was higher for the updated D+F 2011 (AUC of 0.73 95% confidence interval [CI] 0.70–0.76 versus AUC of 0.70 CI 0.67–0.73 for the initial D+F; p < 0.001; odds ratio (or) 1.55 CI 1.29–1.86, net reclassification index 0.11 CI 0.05–0.16, p < 0.001). Conclusions Clinical PTP calculation using the initial and updated D+F prediction models relevantly overestimates the actual prevalence of obstructive CAD in patients with stable chest pain clinically referred for ICA and CT suggesting that further refinements to improve clinical decision-making are needed. Trial registration https://www.clinicaltrials.gov/ct2/show/NCT02400229 Key Points • Clinical pre-test probability calculation using the initial and updated D+F model overestimates the prevalence of obstructive CAD identified by ICA and CT. • Overestimation of disease prevalence is higher for the initial D+F compared with the updated D+F. • Diagnostic accuracy of PTP assessment varies strongly between different clinical sites throughout Europe.

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ESC guidelines on stable chest pain: a comparison of the previous and current risk scores for the assessment of pre-test probability of coronary artery disease

European Heart Journal ◽

10.1093/ehjci/ehaa946.1371 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

S Fyyaz ◽

O Olabintan ◽

S David ◽

S Plein ◽

K Alfakih

Keyword(s):

Coronary Artery Disease ◽

Chest Pain ◽

Coronary Artery ◽

Risk Scores ◽

Severe Stenosis ◽

Mild Stenosis ◽

Esc Guidelines ◽

Artery Disease ◽

Stable Chest Pain ◽

Test Probability

Abstract Introduction The European Society of Cardiology (ESC) guidelines on stable chest pain recommend the use of a pre-test probability (PTP) risk score (RS) which predicts the likelihood of coronary artery disease (CAD) to guide investigation and modality. The 2019 guidelines provide an updated PTPRS compared with 2013 guidelines, adjusted for the lower prevalence of coronary artery disease in contemporary populations. We assessed the performance of the two PTPRS in a cohort of patients with stable chest pain who underwent CT coronary angiography (CTCA) as the first line investigation. Methods We retrospectively searched a 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%) and retrospectively calculated ESC PTP scores for 2013 and 2019 guidelines. Results In total 652 patients underwent CTCA (mean age 55 yrs; IQR 48–63; 330 male). For ESC 2019 PTPRS there were no patients with PTP >85%. 2 patients had PTP 50–85%; 1 patient had moderate stenosis and 1 mild stenosis on CTCA. 267 patients had PTP 15–50%; 23 (9%) had severe stenosis and 35 (13%) moderate stenosis. Finally, 379 patients had PTP <15%; 11 (3%) had severe stenosis and 18 (5%) moderate CTCA stenosis. In comparison, ESC 2013 PTPRS had 2 patients with PTP >85%; 1 had moderate stenosis and 1 had mild stenosis on CTCA. 149 patients had PTP 50–85%; 17 (11%) had severe stenosis and 23 (15%) moderate stenosis. A further 427 patients had a PTP 15–50%; 17 (4%) had severe stenosis and 32 (8%) had moderate stenosis. Lastly, 70 patients had a PTP <15% and two (3%) were found to have a moderate stenosis on CTCA. Conclusions The updated ESC 2019 PTPRS appears to underestimate the presence of CAD given 11 (3%) patients with severe CTCA stenosis would have been missed. Although the 2013 PTPRS was thought to overestimate the prevalence of CAD, it did not miss anyone found to have severe CTCA stenosis. Furthermore, patients with evidence of mild or moderate CAD on CTCA may not have been investigated due to PTP <15% and therefore may not be commenced on medical therapy, to derive a mortality benefit as demonstrated in SCOT-Heart trial. Funding Acknowledgement Type of funding source: None

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107 Nice 2016 stable chest pain guidelines: improved yield of severe coronary artery disease at invasive coronary angiography

10.1136/heartjnl-2019-bcs.104 ◽

2019 ◽

Author(s):

Saad Fyyaz ◽

Ali Rauf ◽

Jonathan Hudson ◽

Olaolu Olabintan ◽

Athanasios Katsigris ◽

...

Keyword(s):

Coronary Artery Disease ◽

Chest Pain ◽

Coronary Artery ◽

Coronary Angiography ◽

Invasive Coronary Angiography ◽

Severe Coronary Artery Disease ◽

Severe Coronary Artery ◽

Artery Disease ◽

Stable Chest Pain

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Coronary Artery Disease Screening Using CT Coronary Angiography

Aerospace Medicine and Human Performance ◽

10.3357/amhp.5522.2020 ◽

2020 ◽

Vol 91 (10) ◽

pp. 812-817

Author(s):

Randy Wang Long Cheong ◽

Brian See ◽

Benjamin Boon Chuan Tan ◽

Choong Hou Koh

Keyword(s):

Systematic Review ◽

Coronary Artery Disease ◽

Coronary Artery ◽

Coronary Angiography ◽

Cardiac Risk ◽

Disease Screening ◽

Ct Coronary Angiography ◽

Major Adverse Cardiovascular Events ◽

Cardiac Events ◽

Artery Disease

BACKGROUND: The increased utility of CT coronary angiography (CTCA) in cardiovascular screenings of aircrew has led to the increased detection of asymptomatic coronary artery disease (CAD). A systematic review of studies relevant to the interpretation of CTCA for the occupational fitness assessment of high-risk vocations was performed, with findings used to describe the development of a pathway for the aeromedical disposition of military aviators with asymptomatic CAD.METHODS: Medline was searched using the terms CT coronary angiogram and screening and prognosis. The inclusion criteria were restricted to study populations ages > 18 yr, were asymptomatic, were not known to have CAD, had undergone CTCA, and with their associations with major adverse cardiovascular events (MACE) and other relevant cardiac outcomes reported.RESULTS: Included in this systematic review were 10 studies. When compared to subjects with no or nonobstructive CAD, those with obstructive CAD on CTCA had hazard ratios (HR) for cardiac events ranging from 1.42 to 105.48. Comparing subjects with nonobstructive CAD and those without CAD on CTCA, a lower HR of 1.19 for cardiac events was found. The annual event rates of subjects with no CAD on CTCA were extremely low, ranging from 0 to 0.5%.CONCLUSIONS: Based on the findings, we suggest that CTCA should only be performed in aircrew with higher cardiac risk profiles. Those found to have no CAD or minimal CAD (i.e., 25% stenosis) in a non-left main coronary artery on CTCA can be returned to flying duties. All other results should be further evaluated with an invasive angiogram.Cheong RWL, See B, Tan BBC, Koh CH. Coronary artery disease screening using CT coronary angiography. Aerosp Med Hum Perform. 2020; 91(10):812817.

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