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

Abstract

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.

Resource implications following expansion of computed tomography coronary angiography: An Australian experience

“…15 The increasing number of invasive coronary angiograms have resulted in a revascularisation rate of 33%. This rate of revascularisation is less than the rates reported in the recent audit of the NICE guidelines in the United Kingdom which showed a revascularisation rate of 52% 16 but is in keeping with local data that show significant variation in revascularisation rates after diagnostic angiogram (17-61%) across Australia. 17 The rate of revascularisation could be related to limitations due to calcification and should improve with advances in technology in reconstruction algorithms, temporal and spatial resolution and X-ray filtering.…”

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

“…The total population contained data from 4627 patients, having removed 666 patients with no demographic data submitted in the previously described service improvement initiative. 5 Patients had a mean age of 57±12 years, mean BMI 29±6 kg/m²; 50% (2301) were female and 50% (2326) male. The females were older than the males (58±11 years vs 55±12 years, p<0.001) but had a lower body mass index (28.7±6 kg/m² vs male 29.0±5 kg/m², p<0.001; table 1 ).…”

“…In the report of the BSCI/BSCCT national audit of downstream testing after a NICE CG95 (2016) CTCA, overuse of ICA was suggested, and the low rate of revascularisation for patients with a moderate stenosis (CAD-RADS 3) was given as a reason to reconsider the need for ‘blanket’ FI in such patients. 5 A trend towards less FI may of course be a direct and appropriate consequence of the Ischemia Research Group’s findings. 8 However, given the sex-related distribution of CAD demonstrated here, maybe we need to consider if we are putting either too many women, or more likely not enough men, forward for stable chest pain assessment with CTCA in the first place.…”

“…Through collaboration with the British Society of Cardiovascular Imaging/British Society of Cardiovascular Computed Tomography (BSCI/BSCCT), we studied 5293 patients across the UK referred for CTCA, following recent-onset chest pain assessment, according to NICE CG95 (2016) as a service improvement initiative. 5 We reported the disease distribution and down-stream testing provided for these patients, of whom 50% were female. Although there has been recent publication on the ‘changing landscape of non-invasive cardiac testing’ in the UK, no clinical sex-related data have been presented.…”

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

“…Morgan-Hughes et al 5 provide us with a robust prospective analysis of real-world practices in eight centres in the UK between 2018 and 2020. This contemporary analysis evaluated 2301 women and 2326 men undergoing CCT wherein women were older and more likely to have normal coronary arteries.…”