Normal coronary angiograms: financial victory from the brink of clinical defeat?

Keavney, Bernard; Haider, Y. M.; McCance, A J; Skehan, J D

doi:10.1136/hrt.75.6.623

Cited by 9 publications

(6 citation statements)

References 11 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…At 1 year, readmission with chest pain was 6.0% (22). The 1-year composite mortality and MACE rate was 1.9% (7), including one MI (0.3%) and one stroke (0.3%).…”

Section: Discussionmentioning

confidence: 98%

“…At 30 days, 1.9% (7) patients were re-admitted to hospital with chest pain and one patient had died of peritonitis (Table 5). At 1 year, readmission with chest pain was 6.0% (22). The 1-year composite mortality and MACE rate was 1.9% (7), including one MI (0.3%) and one stroke (0.3%).…”

Section: Discussionmentioning

confidence: 98%

“…This is curious given that the bulk of available data within the literature supports medical therapy over early intervention in the majority of stable patients (18). However, there are a number of plausible explanations for this: First, the negative (and positive) predictive value of investigations including the exercise treadmill test, stress echocardiogram and nuclear scintigraphy are far from ideal and can result in diagnostic uncertainty, particularly as each provides physiological rather than anatomical data (19)(20)(21); Second, increasing pressure on rapid patient throughput in the healthcare system has led to a 'one-stop' clinic approach, where a definitive management plan is formulated at the initial clinic visit; third, there has been a progressive shift in many healthcare systems (including ours) towards a more 'defensive' style of medical practice with anatomical-imaging often being considered essential for diagnostic certainty (22). Interestingly, the approach of direct referral for angiography without preprocedural non-invasive assessment (at least in those with typical angina and high pretest probability (> 67%) for coronary disease) is advocated by some current guidelines for management of stable angina pectoris (1).…”

Section: Discussionmentioning

confidence: 99%

“…Although non-obstructive CAD is often viewed as failure of preprocedural clinical evaluation, this must be tempered with knowledge that the diagnostic precision afforded by angiography can act as reassurance for both physician and patient (22). Indeed, this finding is generally associated with a good prognosis (from coronary heart disease) with 7-10 year survival rates in the order of 98% (24,25).…”

Section: Discussionmentioning

confidence: 99%

See 3 more Smart Citations

The utility of a ‘non-significant’ coronary angiogram

Wang

Samaranayake

et al. 2015

Int J Clin Pract

View full text Add to dashboard Cite

Summary Background Coronary angiography is the gold standard for assessing coronary artery disease (CAD). In many patients with chest pain, no or mild CAD (< 50% stenosis) is found. It is uncertain whether this ‘non‐significant’ result influences management and outcomes. We reviewed characteristics and outcomes in a contemporary cohort of chest pain referrals who had mild or absent CAD on coronary angiography. Method All patients undergoing coronary angiography at Auckland City Hospital during July 2010–October 2011 were reviewed (n = 2983). Of these, 12.3% (n = 366) underwent coronary angiography for evaluation of chest pain and were found to have absent or mild CAD. These patients were followed up for 2.3 ± 0.6 years. Results Mean age was 60.0 ± 12.3 years, 56.1% were female. The ECG was abnormal in 55.0% of patients. Stress testing for inducible ischaemia was undertaken in 40.7% of patients and was abnormal in 57.7%. Following angiography, 43.2% had no changes to cardiac medications. Additional drug therapy (aspirin, statin, beta‐blockers, ACE‐inhibitor) was commenced in around 14.2–22.1% of cases. These drugs were discontinued in 4.1–8.2% of patients. Rates of major adverse cardiovascular events and readmissions with chest pain were 0.3% (1) and 1.9% (7) respectively at 30 days, and 1.9% (7) and 6.0% (22) at 1 year. Conclusion Although even non‐obstructive atheroma may justify medical therapy to limit disease progression, our findings may suggest that in these cases, invasive coronary angiography, may not lead to the patient/physician reassurance justified by historical data.

show abstract

“…At 1 year, readmission with chest pain was 6.0% (22). The 1-year composite mortality and MACE rate was 1.9% (7), including one MI (0.3%) and one stroke (0.3%).…”

Section: Discussionmentioning

confidence: 98%

Section: Discussionmentioning

confidence: 98%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 2 more Smart Citations

The utility of a ‘non-significant’ coronary angiogram

Wang

Samaranayake

et al. 2015

Int J Clin Pract

View full text Add to dashboard Cite

show abstract

“…Firstly, does the indication itself adequately define the patient or do new indications need to be formulated? For example, angiography may be indicated to reveal normal coronary arteries in patients frequently attending with atypical chest pain and a low pretest probability of CAD,25 26 yet the existing indication lists do not stipulate such indications. Secondly, does the rating of appropriateness reflect current evidence?…”

Section: Discussionmentioning

confidence: 99%

Hypothetical ratings of coronary angiography appropriateness: are they associated with actual angiographic findings, mortality, and revascularisation rate? The ACRE study

Hemingway

2001

Heart

View full text Add to dashboard Cite

Objective-To determine whether ratings of coronary angiography appropriateness derived by an expert panel on hypothetical patients are associated with actual angiographic findings, mortality, and subsequent revascularisation in the ACRE (appropriateness of coronary revascularisation) study. Design-Population based, prospective study. The ACRE expert panel rated hypothetical clinical indications as inappropriate, uncertain, or appropriate before recruitment of a cohort of real patients. Setting-Royal Hospitals Trust, London, UK. Participants-3631 consecutive patients undergoing coronary angiography (no exclusion criteria). Main outcome measures-Angiographic findings, mortality (n = 226 deaths), and revascularisation (n = 1556 procedures) over 2.5 years of follow up. Results-The indications for coronary angiography were rated appropriate in 2253 (62%) patients. 166 (5%) coronary angiograms were performed for indications rated inappropriate, largely for asymptomatic or atypical chest pain presentations. The remaining 1212 (33%) angiograms were rated uncertain, of which 47% were in patients with mild angina and no exercise ECG or in patients with unstable angina controlled by inpatient management. Three vessel disease was more likely among appropriate cases and normal coronaries were more likely among inappropriate cases (p < 0.001). Mortality and revascularisation rates were highest among patients with an appropriate indication, intermediate in those with an uncertain indication, and lowest in the inappropriate group (log rank p = 0.018 and p < 0.0001, respectively). Conclusion-The ACRE ratings of appropriateness for angiography predicted angiographic findings, mortality, and revascularisation rates. These findings support the clinical usefulness of expert panel methods in defining criteria for performing coronary angiography. (Heart 2001;85:672-679) Keywords: coronary artery disease; coronary angiography; coronary artery bypass graft; appropriateness of coronary revascularisationThe management of suspected coronary artery disease (CAD) poses a central question: in which patients should coronary angiography be performed? Angiography is the most frequently performed procedure among people older than 65 years 1 and the rate of angiography is predicted to continue to increase in Europe and the USA.2 3 However, despite the growing number of randomised trials of invasive management of CAD, 4 considerable uncertainty remains about the appropriate indications for coronary angiography. Many of the latest 3 recommendations for the use of coronary angiography are based on non-randomised studies or on unquantified expert consensus.Quantification of the appropriateness of angiography using expert panels allows each patient's indication to be rated as appropriate, uncertain, or inappropriate, by using evidence integrated from randomised and observational studies as well as clinical opinion.5 Angiography is defined as appropriate for a specific indication when the expected health benefit (for example, from subsequent ...

show abstract