Investigation Route of the Coronary Patient in the Public Health System in Curitiba, São Paulo and in Incor - IMPACT Study

Abstract

Background:The investigation of stable coronary artery disease (CAD) and its treatment depend on risk stratification for decision-making on the need for cardiac catheterization and revascularization.Objective:To analyze the procedures used in the diagnosis and invasive treatment of patients with CAD, at the Brazilian Unified Health System (SUS) in the cities of Curitiba, São Paulo and at InCor-FMUSP.Methods:Retrospective, descriptive, observational study of the diagnostic and therapeutic itineraries of the Brazilian public health care system patient, between groups submitted or not to prior noninvasive tests to invasive cardiac catheterization. Stress testing, stress echocardiography, perfusion scintigraphy, catheterization and percutaneous or surgical revascularization treatment procedures were quantified and the economic impact of the used strategies.Results:There are significant differences in the assessment of patients with suspected or known CAD in the metropolitan region in the three scenarios. Although functional testing procedures are most often used the direct costs of these procedures differ significantly (6.1% in Curitiba, 20% in São Paulo and 27% in InCor-FMUSP). Costs related to the procedures and invasive treatments represent 59.7% of the direct costs of SUS in São Paulo and 87.2% in Curitiba. In InCor-FMUSP, only 24.3% of patients with stable CAD submitted to CABG underwent a noninvasive test before the procedure.Conclusion:Although noninvasive functional tests are the ones most often requested for the assessment of patients with suspected or known CAD most of the costs are related to invasive procedures/treatments. In most revascularized patients, the documentation of ischemic burden was not performed by SUS.

Atualização da Diretriz Brasileira de Cardiologia Nuclear – 2020

“…De modo similar ao estudo norte americano, Underwood et al, 6 demonstraram que estratégias que incorporam a cintilografia miocárdica na avaliação de pacientes com doença coronariana estável são mais baratas e igualmente efetivas em comparação às estratégias que incorporam a avaliação anatômica invasiva coronariana. 6 Cerci et al, 7 avaliaram o impacto do uso de exames diagnósticos na trajetória de P com DAC em diferentes cenários no Sistema Único de Saúde (SUS). O achado mais relevante do estudo é de que, apesar dos testes funcionais não invasivos serem os exames mais frequentemente solicitados na avaliação de P com DAC suspeita ou conhecida; a maior parte dos custos da saúde para esse tipo de P está relacionada ao procedimento/tratamento invasivo.…”

“…Outro dado de relevância se refere ao fato de que a maioria dos P do estudo que foram revascularizados não realizou exames para a documentação da carga de isquemia, sendo utilizadas apenas técnicas diagnósticas anatômicas. 7…”

Mexico-city does not look like Beverly-Hills: A multimodality and cardiac imager perspective!

“…Unfortunately, in some countries, low utilization of a technique such as MPI-SPECT, that could serve as a ''filter'' to invasive procedures (Figure 1), results in high rates of invasive coronary angiography and revascularizations. 11 The work from Antonio-Villa et al 1 from Mexico raises a very important issue. Nuclear cardiology still has a tremendous role outside of high-income countries, such as the United States.…”

Nuclear cardiology and CVD in the developing world: Are we applying our scarce resources appropriately? Why is our mortality rate so high?

“…This information is not available in the study of Santos et al, going beyond the scope of that study, but there are data from other government administered centers in Brazil pointing to the fact that patients frequently undergo revascularization without prior functional assessment. 8 Looking at the private sector, in the same country, where resources are not so scarce as in a government hospitals in Brazil, we observe examples where the use of nuclear cardiology can be significant in terms of volume and has been growing in many large center. To illustrate this, we show the utilization rates of nuclear cardiology procedures at two referral centers for non-invasive cardiac imaging in a city of 1.7 million inhabitants in Latin America (Curitiba, Brazil), demonstrating progressively the increasing utilization between 2007 and 2015, even compared to other diagnostic modalities such as CMR and CCTA (Figure 2).…”

“…At the same time, on a given environment, where the use of non-invasive imaging is modest or non-existent, many patients might go directly to the invasive catheterization laboratory, leading to revascularization, despite the lack of benefit shown in the literature for most stable patients. 8 Any procedures, invasive or non-invasive, should be applied and guided by scientific evidence and AUC whenever available.…”