New Stable Chest Pain Guidance in the UK ‘NICE’ to have, difficult to implement

Dr Tim Fairbairn

MBChB, MRCP, PhD

Consultant Imaging Cardiologist

Liverpool Heart and Chest Hospital, United Kingdom

2010

Risk Stratification

Diagnostic strategy according to PTP distribution

CAC scoring in symptomatic patients

Men

Women

Effect of implementing NICE 2010 on cardiac services

NICE CG95 Reduces number and cost of investigations

Invasive coronary angiography

Over half of patients who undergo

invasive angiography have no disease and could have avoided

ICA

Findings During Invasive Coronary Angiograms

Non-

obstructive

CAD

Obstructive

CAD 55%

Patel et al, NEJM 2010 Patel et al, AHJ 2014

Diagnostic yield of ICA

Non-invasive functional imaging and inappropriate ICA rates

Diagnostic Conundrum

ESC 2013

Stable Coronary Artery Disease

Post Test Probability

• Identification of SCAD patients at high risk of CV death / nonfatal-MI

• ESC 2013 SCAD guidelines:

• High Risk = mortality >3%/pa

• Intermediate risk = ≥1% but ≤3%

• Low risk = <1%

Revascularisation

CTCA and Diagnosis

• Low- intermediate risk

• High negative predictive value

• Moderate accuracy if positive

• Potential to identify risk

• Anatomical not functional assessment

CTCA Radiation Dose

Functional Tests and Prognosis

Shaw et , JNC 2012

SPECT Stress Echo Stress MRI

Comparative definitions of moderate –severe ischaemia

Shaw et al. JACC-CVI 2014 7(6): 593-604

Appropriate revascularisation and Non-invasive testing

Management of CAD

CCTA Evaluation for clinical outcomes (CONFIRM)

Accuracy and outcomes of CCTA vs functional testing

Outcomes of Anatomical vs Functional Testing PROMISE

• No difference in functional vs anatomical assessment

– Primary event rate 3.3% vs 3% (p=0.75)

• CTA

– Higher incidence of CA (12 vs 8%)

– lower incidence of unobstructive CA disease (3 vs 4%)

– Higher revascularisation 6.2 vs 3.2%

– Higher radiation dose (13msv)

Douglas P, NEJM 2015: PROMISE study

CTCA in Suspected CAD SCOT HEART

• 4000 patients randomised to CTA or Standard care

• CTCA

– increased diagnostic certainty

– Reduced stress tests

– Increased CA

– Changed treatment regimes

• No difference in

– Death

– MI

– Hospitalisation

– Revasularisation

Clinical Effectiveness

Clinical Effectiveness

CCTA and high risk populations

Anatomical and physiological assessment

Anatomy Identify Obstructive CAD

Invasive

Non-

Invasive

Function Identify lesion-specific ischemia

that may benefit from PCI

Diagnostic Accuracy of cardiac imaging

Resource modeling

Cardiac enabled

scanners

Sites performing > 40/

month

Absolute increase

needed

Utilization of CCTA & Outpatient Invasive Coronary Angiography in Ontario, Canada

CCTA Growth - “Slow &

Steady”

Elective Invasive

Angiography &

Revascularization

Significantly Reduced post-

CCTA Initiation

1,044 Fewer Invasive

Angiograms / Year

Roifman JCCT 2015;9:567-571.

Cardiac CT Coverage

Begins

10.1 million Adults in Ontario

Cost-Effectiveness

290%

increase

Practical implementation

• Delivering place and population care

– Trust infrastructure and workforce planning

– Sustainability and transformation programmes

• Providing national level support

– Proactive management of new diagnostic strategies

– Research and development innovation

– Societies (BCS, BSCCT)

• Financial sustainability and value for money

Chest Pain algorithm

Chest Pain algorithm