175 Upstream investigation of stable chest pain in patients undergoing invasive coronary angiography: concordance with nice guidelines and likelihood of revascularisation. (6th June 2022)

• Record Type: Journal Article
• Authors: Chow, Jocelyn; Beattie, Anna; Bagnall, Alan
• Is Part Of: Heart. Volume 108(2022)Supplement 1
• Page Start: A136
• Page End: A137
• Publication Date: 2022-06-06
• Subjects: Angina -- Investigation -- Guideline; Heart -- Diseases -- Treatment -- Periodicals; Cardiology -- Periodicals; 616.12
• DOI: 10.1136/heartjnl-2022-BCS.174
• Languages: English
• ISSNs: 1355-6037

Abstract

Abstract : Introduction: The 2016 National Institute for Health and Care Excellence (NICE) CG95 guideline for investigation of patients with stable chest pain without known coronary artery disease (CAD) recommends CT coronary angiography (CTCA) for first-line investigation. For those with indeterminate CAD on CTCA, a non-invasive functional test is recommended, using myocardial perfusion scintigraphy, dobutamine stress echocardiography, stress MRI or CT-Fractional Flow Reserve (CT-FFR). Invasive diagnostic coronary angiography (iCA) is considered a 3rd line test for stable chest pain assessment in the Evidence Based Interventions Guidance from The Academy of Medical Royal Colleges. We assessed concordance with CG95 in patients attending for iCA and likelihood of subsequent revascularisation according to upstream investigation. Methods: All patients undergoing iCA at a UK tertiary referral cardiac centre between 1 March 2021 and 28 May 2021 were identified. Patients presenting with acute coronary syndromes, pre-existing CAD (defined as previous PCI or coronary artery bypass graft (CABG)), and those for coronary assessment prior to non-coronary cardiac surgery were excluded as outside the CG95 guideline scope.Hospital electronic records were accessed using patient NHS number. All tests and events in the 24 months prior to iCA were recorded. An extended workup time was used to allow for pandemic related delays. Patients who underwent revascularisation were identified as those having PCI immediately or up to 4 weeks after iCA, and CABG within 3 months.RESULTS209 patients attended for elective iCA. 106 patients (50.7%) with no known CAD met NICE CG95 chest pain pathway criteria (Figure 1). Of these, 25 patients (23.6%) had no non-invasive tests prior to iCA. 81 patients (76.4%) underwent ≥1 non-invasive test, with 58 patients having any functional test and 23 having only CTCA (Figure 2).Revascularisation was performed in 69/106 patients (65.1%: 64 PCI; 5 CABG). Of those with prior functional imaging 41/58 (70.7%) underwent revascularisation. Of the 25 patients without prior functional or anatomical imaging, 9 (36.0%) had revascularisation. The percentage of patients revascularized stratified by upstream investigation pathway are listed in Table 1. Conclusions: Six years following NICE CG95 publication, nearly a quarter of chest pain patients with no known CAD are referred for iCA without prior non-invasive testing. Only 31.1% had both CT and a functional test. Revascularisation rates were lowest in patients without prior non-invasive investigation, suggesting history and examination are poor predictors of need for revascularisation. In contrast, prior non-invasive testing was associated with higher rates of revascularisation, avoiding the risks of unnecessary iCA for many patients. Ensuring patients are likely to need revascularisation or intracoronary assessment prior to iCA is likely to improve catheter lab efficiency in a capacity constrained system. Conflict of Interest: N/A