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

Transcription

1 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

2 2010

3 Risk Stratification

4 Diagnostic strategy according to PTP distribution

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6 CAC scoring in symptomatic patients Men Women

7 Effect of implementing NICE 2010 on cardiac services

8 NICE CG95 Reduces number and cost of investigations

9 Invasive coronary angiography Findings During Invasive Coronary Angiograms Over half of patients who undergo invasive angiography have no disease and could have avoided ICA Obstructive CAD 55% Nonobstructive CAD Patel et al, NEJM 2010 Patel et al, AHJ 2014

10 Diagnostic yield of ICA

11 Non-invasive functional imaging and inappropriate ICA rates

12 Diagnostic Conundrum

13 ESC 2013

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17 Stable Coronary Artery Disease Post Test Probability Revascularisation 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%

18 CTCA and Diagnosis Low- intermediate risk High negative predictive value Moderate accuracy if positive Potential to identify risk Anatomical not functional assessment

19 CTCA Radiation Dose

20 Functional Tests and Prognosis SPECT Stress Echo Stress MRI Shaw et, JNC 2012

21 Comparative definitions of moderate severe ischaemia Shaw et al. JACC-CVI (6):

22 Appropriate revascularisation and Non-invasive testing

23 Management of CAD

24 CCTA Evaluation for clinical outcomes (CONFIRM)

25 Accuracy and outcomes of CCTA vs functional testing

26 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

27 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

28 Clinical Effectiveness

29 Clinical Effectiveness

30 CCTA and high risk populations

31 Anatomical and physiological assessment Anatomy Identify Obstructive CAD Function Identify lesion-specific ischemia that may benefit from PCI Invasive Non- Invasive

32 Diagnostic Accuracy of cardiac imaging

33 Resource modeling Cardiac enabled scanners Sites performing > 40/ month Absolute increase needed

34 Utilization of CCTA & Outpatient Invasive Coronary Angiography in Ontario, Canada CCTA Growth - Slow & Steady Cardiac CT Coverage Begins Elective Invasive Angiography & Revascularization Significantly Reduced post- CCTA Initiation 10.1 million Adults in Ontario 1,044 Fewer Invasive Angiograms / Year Roifman JCCT 2015;9:

35 Cost-Effectiveness

36 290% increase

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38 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

39 Chest Pain algorithm

40 Chest Pain algorithm