Correction: Sex-based inequalities in contemporary UK hospital management of 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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Coronary CT angiography for patients with stable chest pain in the Emergency Department; an appraisal of current and emerging evidence

Internal Medicine Journal ◽

10.1111/j.1445-5994.2011.02652.x ◽

2012 ◽

Vol 42 (2) ◽

pp. 226-228 ◽

Cited By ~ 1

Author(s):

C. Hamilton-Craig ◽

O. C. Raffel ◽

M. Pincus ◽

M. Hansen ◽

R. E. Slaughter ◽

...

Keyword(s):

Emergency Department ◽

Chest Pain ◽

Ct Angiography ◽

Coronary Ct Angiography ◽

Coronary Ct ◽

Stable Chest Pain

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Coronary CTA reduced risk for coronary events at 5 years in patients with stable chest pain

Annals of Internal Medicine ◽

10.7326/acpjc-2018-169-12-070 ◽

2018 ◽

Vol 169 (12) ◽

pp. JC70

Author(s):

Michael P. Hudson

Keyword(s):

Chest Pain ◽

Coronary Cta ◽

Coronary Events ◽

Stable Chest Pain ◽

Reduced Risk

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P6175Prediction of coronary revascularization by coronary computed tomography angiography derived fractional flow reserve - different algorithms for interpretation

European Heart Journal ◽

10.1093/eurheartj/ehz746.0781 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

K T Madsen ◽

K T Veien ◽

B L Noergaard ◽

P Larsen ◽

L Deibjerg ◽

...

Keyword(s):

Chest Pain ◽

Fractional Flow Reserve ◽

Predictive Value ◽

Diagnostic Performance ◽

Coronary Revascularization ◽

Standard Of Care ◽

Fractional Flow ◽

Coronary Cta ◽

Flow Reserve ◽

Stable Chest Pain

Abstract Introduction Coronary CT angiography (CTA) derived fractional flow reserve (FFRct) is increasingly used for guiding referral to invasive procedures in patients with stable chest pain. However, optimal interpretation of FFRct-analysis in terms of location and threshold of applied FFRct-values is unclear. Purpose To evaluate the clinical performance of various vessel-specific physiological FFRct derived measures of ischemia for prediction of standard of care guided coronary revascularization in patients with stable chest pain and coronary artery disease as determined by coronary CTA. Methods Retrospective study in patients with stable chest pain referred for coronary angiography based on coronary CTA. Standard acquired coronary CTA data sets were transmitted for core-laboratory analysis at HeartFlow. Any FFRct value in the major coronary arteries ≥1.8 mm in diameter, including side branches, were registered. Lesions were categorized as positive for ischemia using 6 different algorithms: Lowest in vessel FFRct-value (1) ≤0.75 or (2) ≤0.80; 2 cm distal-to-lesion FFRct-value (3) ≤0.75 or (4) ≤0.80; ΔFFRct (5) ≥0.06 or a combination of 2 and 5. The personnel responsible for downstream patient management had no information regarding FFRct test results. Results A total of 172 patients were included. Revascularization was performed in 62 (35%) patients. The diagnostic performance of different FFRct algorithms for predicting standard of care guided coronary revascularization is shown in the Table. Revascularization Predictions by FFRct N=172 Diagnostic performance FFRCT false negative FFRCT false positive Values given as (%) No. of revasc vessels No. of abnormal vessels FFRCT Algorithm Sens Spec PPV NPV Acc 1 2 3 1 2 3 Distal FFRCT ≤0.75 77 68 58 84 72 12 2 0 29 5 1 Distal FFRCT ≤0.80 92 43 48 90 61 5 0 0 40 20 3 Lesion-specific FFRCT ≤0.75 68 86 74 83 80 17 3 0 12 3 0 Lesion-specific FFRCT ≤0.80 82 78 68 89 80 10 2 0 21 3 1 ΔFFRCT ≥0.06 98 36 47 98 59 1 0 0 51 19 0 Combinationa 92 54 53 92 67 5 0 0 39 12 0 aDistal FFRCT ≤0.80 and ΔFFRCT ≥0.06. Sens = sensitivity; Spec = specificity; PPV = positive predictive value; NPV = negative predictive value; Acc = accuracy; FFRCT = fractional flow reserve derived from coronary CTA; ΔFFRCT = difference between FFRCT-value immediately proximal and distal to lesion; Revasc = revascularized. Conclusion The diagnostic performance of FFRct in terms of predicting standard of care guided coronary revascularization is dependent on the applied algorithm for interpretation of the FFRct-analysis.

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Prognostic value of dipyridamole technetium-99m sestamibi myocardial tomography in patients with stable chest pain who are unable to exercise

The American Journal of Cardiology ◽

10.1016/0002-9149(94)90927-x ◽

1994 ◽

Vol 73 (9) ◽

pp. 647-652 ◽

Cited By ~ 51

Author(s):

Henry G. Stratmann ◽

Beaver R. Tamesis ◽

Liwa T. Younis ◽

Mark D. Wittry ◽

D. Douglas Miller

Keyword(s):

Chest Pain ◽

Prognostic Value ◽

Technetium 99M Sestamibi ◽

Technetium 99M ◽

Stable Chest Pain

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Pre-test probability of obstructive coronary artery disease in the new guidelines: too much, too little or just enough?

European Heart Journal ◽

10.1093/ehjci/ehaa946.1380 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

P Lopes ◽

F Albuquerque ◽

P Freitas ◽

B Rocha ◽

G Cunha ◽

...

Keyword(s):

Coronary Artery Disease ◽

Chest Pain ◽

Obstructive Coronary Artery Disease ◽

P Value ◽

Coronary Syndrome ◽

Luminal Stenosis ◽

Artery Disease ◽

Stable Chest Pain ◽

New Guidelines ◽

Test Probability

Abstract Background Previous 2013 ESC guidelines recommended the use of the Modified Diamond-Forrester method to assess the pre-test probability (PTP) of obstructive coronary artery disease (CAD). The 2019 ESC Chronic Coronary Syndrome guidelines updated this recommendation with a major downgrade in PTP. The aim of this study was to compare the performance of these two methods in patients with stable chest pain undergoing coronary computed tomography angiography (CCTA) for suspected CAD. Methods We performed a retrospective analysis on prospectively collected data from a cohort of consecutive patients undergoing CCTA for suspected CAD from October 2016 to 2019. Key exclusion criteria were age <30 years-old, known CAD, suspected acute coronary syndrome or symptoms other than chest pain. Obstructive CAD was defined as any luminal stenosis ≥50% on CCTA. Whenever invasive coronary angiography (ICA) was subsequently performed, patients were reclassified if luminal stenosis was <50%. The two PTP prediction models were assessed for calibration and discrimination. Results A total of 320 patients (median age 63 years [IQR 53–70], 59% women) were included. Chest pain characteristics were: 48% atypical angina, 38% non-anginal chest pain, 14% typical angina. The observed prevalence of obstructive CAD was 16.3% (n=52). Patients with obstructive CAD were more often male, were significantly older and had a higher prevalence of typical angina and cardiovascular risk factors (except for family history of CAD). On average, individual PTP was 22.1% lower in the new guidelines. The 2013 prediction model significantly overestimated the likelihood of obstructive CAD (mean PTP 37.3% vs 16.3%; relative overestimation of 130%, p-value for miscalibration 0.005). The updated 2019 method showed good calibration for predicting the likelihood of obstructive CAD (mean PTP 15.2% vs 16.3%; relative underestimation of 6.5%, p-value for miscalibration 0.712). The two approaches showed similar discriminative power, with a C-statistics of 0.730 and 0.735 for the 2013 and 2019 methods, respectively (p-value for comparison 0.933). Stratification by gender produced similar results. Conclusions In patients with stable chest pain undergoing CCTA, the updated 2019 prediction model allows for a more precise estimation of pre-test probabilities of obstructive CAD than the previous model. Adoption of this new score may improve disease prediction and change the downstream diagnostic pathway in a significant proportion of cases. Graph 1 Funding Acknowledgement Type of funding source: None

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