39 Relevance of the ischemia trial to real-world clinical services. (17th July 2020)

• Record Type: Journal Article
• Authors: Gall, Alexander; Connolly, Georgia; Mora, Jessica; Kashyap, Mavin; Dastidar, Amardeep; Joshi, Nikhil; Dorman, Stephen; De Silva, Kalpa; Strange, Julian; Johnson, Tom; Sammut, Eva
• Is Part Of: Heart. Volume 106(2020)Supplement 2
• Page Start: A34
• Page End: A34
• Publication Date: 2020-07-17
• Subjects: Acute coronary syndrome -- Rapid access chest pain clinic -- ISCHEMIA trial; Heart -- Diseases -- Treatment -- Periodicals; Cardiology -- Periodicals; 616.12
• DOI: 10.1136/heartjnl-2020-BCS.39
• Languages: English
• ISSNs: 1355-6037

Abstract

Abstract : Background: The recently presented ISCHEMIA trial demonstrates that optimal medical therapy (OMT) is not inferior to an early interventional approach for patients with stable angina. These results have the potential to significantly impact on future care pathways. In the UK, the rapid access chest pain clinic (RACPC) is increasingly used as an open access resource. This study compared how the ISCHEMIA study may apply to real-world clinical services. Methods: Electronic notes of patients assessed in our high-volume Rapid Access Chest Pain Clinic (RACPC) within a 12-month period (2018–19) were reviewed. Patients retrospectively meeting key inclusion criteria for the ISCHEMIA trial were selected. Information on demographics, symptoms, initial investigations and management were obtained. Results: 2416 patients were assessed in the RACPC during the study period. Of these, 378 (15.6%) presented with symptoms thought to represent typical anginal chest pain (CP). Within this group, 158 patients (41.8%) were excluded (62 due to ACS, 91 due to known CAD, 3 due to known severe LV impairment, 2 due to eGFR <30mL/min). This resulted in a total of 220 patients meeting key inclusion criteria of the ISCHEMIA trial, representing 58.2% of the typical chest pain population but only 9.1% of all patients seen in the RACPC. These patients had a median age of 60 years, 96 (44%) female, 44 (20%) had diabetes, 119 (54.1%) had high cholesterol, 104 (47.3%) had a family history, 115 (52.3%) had hypertension and 32 (14.5%) were smokers. From these 220 patients, 48 (21.8%) had a CT coronary angiogram (CTCA) as their first line investigation (42 completed). Of these patients, 1 (2.4%) patient had findings suggestive of significant left main stem (LMS) disease. 18 (8.2%) patients had stress echocardiography or stress perfusion CMR requested as their first line investigation (15 completed), 4 were positive for inducible ischaemia. 143 (65%) patients underwent invasive coronary angiogram (ICA) as their first line investigation (112 completed). In total 43 patients (19.5%) patients subsequently underwent revascularisation (8 patients for LMS disease, 11 patients due to multivessel disease, 24 patients treated with PCI). The median wait time for a CTCA was 55 days compared to 165.5days for ICA. See Table 1 for more details. Conclusion: In the real-world, patients present with undifferentiated chest pain, consequently the outcomes of the ISCHEMIA trial must be considered cautiously. Within our cohort of 2416 patients, only 220 patients met key inclusion criteria for the trial. Our patients were younger, more frequently female and not diabetic. Referral for invasive tests was the most common pathway, however service pressures resulted in a significant delay to treatment. Ultimately, only 19.5% received revascularisation, compared to 80% of patients in the invasive arm of ISCHEMIA. It is unclear how the results of the ISCHEMIA trial will ultimately impact on UK practice, but it is clear that OMT plays a central role. References: Hochman JS, Reynolds HR, Bangalore S, O'Brien SM, Alexander KP, Senior R, et al . Baseline characteristics and risk profiles of participants in the ISCHEMIA randomized clinical trial. JAMA Cardiol [Internet]. 2019 Mar 1;4(3) :273–86. Available from: https://pubmed.ncbi.nlm.nih.gov/30810700 ISCHEMIA Research Group. ISCHEMIA Study Results [Internet]. 2020 [cited 2 Mar 2020]. Available from: https://www.ischemiatrial.org/ Conflict of Interest: None