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