How effective are rapid access chest pain clinics? Prognosis of incident angina and non-cardiac chest pain in 8762 consecutive patients

Effectiveness of rapid access chest pain clinics: a systematic review of patient outcomes and resource utilisation

BACKGROUND

Rapid Access Chest Pain Clinics (RACPC) are widely used for the outpatient assessment of chest pain, but there appears to be limited high-quality evidence justifying this model of care. This study aimed to review the literature to determine the effectiveness of RACPCs.

METHODS

A systematic review of studies evaluating the effectiveness of RACPCs was conducted to assess the quality of the evidence supporting this model. Outcomes related to effectiveness included major adverse cardiovascular events, emergency department reattendance, cost-effectiveness and patient satisfaction. Study quality was assessed using the RoB 2 tool, Newcastle-Ottawa quality assessment tool or the Consolidated Criteria for Reporting Qualitative Studies checklist, as appropriate.

RESULTS

Thirty-two studies were eligible for inclusion, including one randomised trial. Five analytical cohort studies were included, with three comparing outcomes against non-RACPC controls. Three qualitative studies were included. Most reports were descriptive. Findings were consistent with RACPCs being associated with favourable clinical outcomes, reduced emergency department reattendance, cost-effectiveness and high patient satisfaction. However, there was significant heterogeneity in care models, and overall literature quality was low, with a high risk of publication bias.

CONCLUSION

While the literature suggests RACPCs are safe and efficient, the quality of the available evidence is limited. Further high-quality data from adequately controlled clinical trials or large scare registries are needed to inform healthcare resource allocation decisions.

PROSPERO REGISTRATION NUMBER

CRD42023417110.

The prevalence of coronary artery disease in patients presenting with 'non-anginal chest pain'

The National Institute for Health and Care Excellence (NICE) advise against routine testing for coronary artery disease (CAD) in patients with non-anginal chest pain (NACP). This clinical audit sought to establish the prevalence of significant CAD in this cohort using computed tomography angiography (CTCA) and evaluate differences in the prevalence of cardiovascular risk factors between those with and without obstructive coronary disease. Over 23 months, 866 patients with NACP underwent CTCA. Patients were separated into three groups for analysis depending on the degree of CAD on CTCA using the CAD-RADS (Coronary Artery Disease Reporting and Data System) scoring system; no evidence of CAD (group 1), a degree of CAD requiring medical therapy only (group 2), significant CAD defined as a CAD-RADS score 4A/B or 5 (group 3). Cardiovascular risk factors were compared between the groups. We found 11.5% had significant CAD (group 3), 58.3% required medical therapy (group 2) and 30.1% had no CAD (group 1). There were 32 patients who required coronary revascularisation. Patients in group 2 and 3 were more likely to be male (p<0.001) and older (p<0.001) when compared to patients in group 1. Patients in group 3 were more likely to be hypertensive (p=0.008) and have higher Qrisk2 scores (p<0.001) when compared with those in group 1. In conclusion, NICE guidelines for NACP may result in a significant proportion of patients with CAD being underdiagnosed, including some with severe disease requiring revascularisation. This analysis suggests age, male gender, Qrisk2 score and hypertension are predictors of CAD in this cohort.

Non-cardiac Chest Pain in Japan: Prevalence, Impact, and Consultation Behavior - A Population-based Study

Background/Aims

Non-cardiac chest pain (NCCP) is defined as recurring angina-like retrosternal chest pain of non-cardiac origin. Information about the epidemiology of NCCP in Japan is lacking. We aim to determine the prevalence and characteristics of NCCP in the Japanese general population.

Methods

Two internet-based surveys were conducted among the general population in March 2017. Questions investigated the characteristics of symptoms associated with chest pain and consultation behavior. Quality of life, anxiety, depression, and gastroesophageal reflux disease were analyzed.

Results

Five percent of the survey respondents reported chest pain. Subjects with chest pain showed higher frequencies of anxiety and depression and lower quality of life. Among subjects with chest pain, approximately 30% had sought medical attention for their symptoms. Among all consulters, 70% were diagnosed with NCCP. Females were less likely to seek consultations for chest pain than males. Further, severity and frequency of chest pain, lower physical health component summary score, and more frequent gastroesophageal reflux disease were associated with consultation behavior. Subjects with NCCP and cardiac chest pain experienced similar impacts on quality of life, anxiety, and depression. Among subjects with NCCP, 82% visited a primary-care physician and 15% were diagnosed with reflux esophagitis.

Conclusions

The prevalence of chest pain in this sample of a Japanese general population was 5%. Among all subjects with chest pain, less than one-third consulted physicians, approximately 70% of whom were diagnosed with NCCP. Sex and both the severity and frequency of chest pain were associated with consultation behavior.

National audit of pathways in epileptic seizure referrals (NAPIER): A national, multicentre audit of first seizure clinics throughout the UK and Ireland

BACKGROUND

Current guidelines set clinical standards for the management of suspected first seizures and epilepsy. We aimed to assess if these standards are being met across first seizure clinics nationally, to describe variations in care and identify opportunities for service delivery improvement.

METHODS

Multicentre audit assessing the care of adults (≥16 years) referred to first seizure clinics from 31st December 2019 going backwards (30 consecutive patients per centre). Patients with pre-existing diagnosis of epilepsy were excluded. Anonymised referral, clinic, and follow-up data are reported with descriptive statistics.

RESULTS

Data provided for 727 patients from 25 hospitals in the UK and Ireland (median age 41 years [IQR 26-59], 52% males). Median time to review was 48 days (IQR 26-86), with 13.8% (IQR 3.3%-24.0%) of patients assessed within 2 weeks. Seizure recurrence was seen in 12.7% (IQR 6.6%-17.4%) of patients awaiting first appointment. Documentation for witness accounts and driving advice was evident in 85.0% (IQR 74.0%-100%) and 79.7% (IQR 71.2%-96.4%) of first seizure/epilepsy patients, respectively. At first appointment, discussion of sudden unexpected death in epilepsy was documented in 30.1% (IQR 0%-42.5%) of patients diagnosed with epilepsy. In epilepsy patients, median time to MRI neuroimaging was 37 days [IQR 22-56] and EEG was 30 days [IQR 19-47]. 30.4% ([IQR 0%-59.5%]) of epilepsy patients were referred to epilepsy nurse specialists.

CONCLUSIONS

There is variability nationally in the documented care of patients referred to first seizure clinics. Many patients are facing delays to assessment with epilepsy specialists with likely subsequent impact on further management.

NICE guidelines in the Sunderland RACPC cohort study: one size does not fit all

At least 5% of GP and accident and emergency (A&E) attendances are undifferentiated chest pain. Rapid access chest pain clinics (RACPC) offer urgent guideline-directed management of suspected cardiac chest pain. The National Institute for Health and Care Excellence (NICE) recommends computed tomography coronary angiography (CTCA) as a first-line investigation. We evaluated the effectiveness and efficiency of a local RACPC. Retrospective analysis of unselected referrals to a RACPC in the Northeast of England was conducted for 2021. Baseline demographics and major adverse cardiovascular events (MACE) were compared between typical, atypical and non-angina. Anatomical and functional imaging results were recorded. Backward stepwise binary logistic regression modelled obstructive coronary artery disease (CAD) incidence. There were 373/401 (93.0%) patients with chest pain; 139 (37.3%) typical angina, 122 (32.8%) atypical angina and 112 (30.0%) non-angina. Typical angina patients were older (p<0.001) with more cardiovascular risk factors (p<0.001) and increased risk of obstructive CAD (adjusted odds ratio [OR] 6.27, 95% confidence interval [CI] 2.93 to 13.38) and MACE (9.4%, p=0.029). In total, 164 (44.0%) had invasive coronary angiography (ICA) within 7.4 ± 4.8 weeks; 19.5% had normal coronary arteries, 26.2% had obstructive CAD and 22.6% proceeded to invasive haemodynamic assessment ± PCI without major procedural complications. There were 39 (10.5%) who had CTCA within 34.6 ± 18.1 weeks; 25.6% needed ICA to clarify diagnosis. In conclusion, typical angina patients were at heightened risk of cardiovascular events. In the absence of adequate CTCA capacity, greater reliance on ICA still facilitated accurate diagnosis with options for immediate revascularisation, timely and safely, in the right patients. Better risk stratification and expansion of non-invasive imaging can improve local RACPC service delivery in the wider Northeast cardiology network.

Determining cardiovascular risk in patients with unattributed chest pain in UK primary care: an electronic health record study

AIMS

Most adults presenting in primary care with chest pain symptoms will not receive a diagnosis ('unattributed' chest pain) but are at increased risk of cardiovascular events. To assess within patients with unattributed chest pain, risk factors for cardiovascular events and whether those at greatest risk of cardiovascular disease can be ascertained by an existing general population risk prediction model or by development of a new model.

METHODS AND RESULTS

The study used UK primary care electronic health records from the Clinical Practice Research Datalink linked to admitted hospitalizations. Study population was patients aged 18 plus with recorded unattributed chest pain 2002-2018. Cardiovascular risk prediction models were developed with external validation and comparison of performance to QRISK3, a general population risk prediction model. There were 374 917 patients with unattributed chest pain in the development data set. The strongest risk factors for cardiovascular disease included diabetes, atrial fibrillation, and hypertension. Risk was increased in males, patients of Asian ethnicity, those in more deprived areas, obese patients, and smokers. The final developed model had good predictive performance (external validation c-statistic 0.81, calibration slope 1.02). A model using a subset of key risk factors for cardiovascular disease gave nearly identical performance. QRISK3 underestimated cardiovascular risk.

CONCLUSION

Patients presenting with unattributed chest pain are at increased risk of cardiovascular events. It is feasible to accurately estimate individual risk using routinely recorded information in the primary care record, focusing on a small number of risk factors. Patients at highest risk could be targeted for preventative measures.

CT coronary angiography first prior to rapid access chest pain clinic review: a retrospective feasibility study

OBJECTIVES

Since rapid access chest pain clinics (RACPC) were established to streamline stable chest pain assessment, CT coronary angiography (CTCA) has become the recommended investigation for patients without known coronary artery disease (CAD), with well-defined indications. This single-centre retrospective study assessed the feasibility of General Practice (GP)-led CTCA prior to RACPC.

METHODS

RACPC pathway patients without pre-existing CAD electronic records were reviewed (September-October 2019). Feasibility assessments included appropriateness for RACPC, referral clinical data vs RACPC assessment for CTCA indication and safety, and a comparison of actual vs hypothetical pathways, timelines and hospital encounters.

RESULTS

106/172 patients screened met inclusion criteria (mean age 61 ± 14, 51% female). 102 (96%) referrals were 'appropriate'. No safety concerns were identified to preclude a GP-led CTCA strategy. The hypothetical pathway increased CTCA requests vs RACPC (84 vs 71), whilst improving adherence to guidelines and off-loading other services. 22% (23/106) had no CAD, representing cases where one hospital encounter may be sufficient. The hypothetical pathway would have reduced referral-to-diagnosis by at least a median of 27 days (interquartile range 14-33).

CONCLUSION

A hypothetical GP-led CTCA pathway would have been feasible and safe in a real-world RACPC patient cohort without pre-existing CAD. This novel strategy would have increased referrals for CTCA, whilst streamlining patient pathways and improved NICE guidance adherence.

ADVANCES IN KNOWLEDGE

GP-led CTCA is a feasible and safe pathway for patients without pre-existing CAD referred to RACPC, reducing hospital encounters required and may accelerate time to diagnosis. This approach may have implications and opportunities for other healthcare pathways.

Looking forward to a decade of the biopsychosocial model

The topic of this article is the biopsychosocial model. My main contention is that - notwithstanding doubts as to what exactly it is, or indeed whether it is anything - there is a coherent account of it, in terms of both applications to particular health conditions and mechanisms with wide application. There is accumulating evidence from recent decades that psychosocial as well as biological factors are implicated in the aetiology and treatment of a large range of physical as well as mental health conditions. The original proposer of the biopsychosocial model, George Engel, back in 1977, was substantially correct about what he saw was on its way.

Mindfulness-based intervention in patients with persistent pain in chest (MIPIC) of non-cardiac cause: a feasibility randomised control study

Objective

The study evaluated the feasibility of mindfulness-based cognitive therapy (MBCT) in patients with non-cardiac chest pain by assessing their willingness to participate and adhere to the programme, and for these data to help further refine the content of MBCT for chest pain.

Patients and methods

This prospective 2:1 randomised controlled trial compared the intervention of adapted MBCT as an addition to usual care with just usual care in controls. Among 573 patients who attended the rapid access chest pain clinic over the previous 12 months and were not diagnosed with a cardiac cause but had persistent chest pain were invited. The intervention was a 2-hour, weekly, online guided 8-week MBCT course. Compliance with attendance and the home practice was recorded. Enrolled patients completed the Seattle angina questionnaire (SAQ), Hospital Anxiety and Depression Scale, Cardiac Anxiety Questionnaire, Five-Facet Mindfulness Questionnaire, and Euro Quality of Life–5 Dimensions–5 Level at baseline assessment and after 8-week period.

Results

Persistent chest pain was reported by 114 patients. Of these, 33 (29%) patients with a mean age of 54.2 (±12.2) years and 68% women, consented to the study. Baseline questionnaires revealed mild physical limitation (mean SAQ, 76.8±25), high levels of anxiety (76%) and depression (53%), modest cardiac anxiety (CAQ,1.78±0.61) and mindfulness score (FFMQ, 45.5±7.3). Six patients subsequently withdrew due to bereavement, caring responsibilities and ill health. Of the remaining 27 participants, 18 in the intervention arm attended an average of 5 sessions with 61% attending ≥6 sessions. Although not statistically powered, the study revealed a significant reduction in general anxiety, improved mindfulness and a trend towards improvement in SAQ scores in the intervention arm.

Conclusion

One-third of patients with persistent non-cardiac chest pain were willing to participate in mindfulness-based therapy. An improvement in anxiety and mindfulness was detected in this feasibility study. A larger trial is required to demonstrate improvement in chest pain symptoms.

Development and Validation of Retinal Vasculature Nomogram in Suspected Angina Due to Coronary Artery Disease

AIMS

To develop and validate a nomogram using retinal vasculature features and clinical variables to predict coronary artery disease (CAD) in patients with suspected angina.

METHODS

The prediction model consisting of 795 participants was developed in a training set of 508 participants with suspected angina due to CAD, and data were collected from January 2018 to June 2019. The held-out validation was conducted with 287 consecutive patients from July 2019 to November 2019. All patients with suspected CAD received optical coherence tomography angiography (OCTA) examination before undergoing coronary CT angiography. LASSO regression model was used for data reduction and feature selection. Multivariable logistic regression analysis was used to develop the retinal vasculature model for predicting the probability of the presence of CAD.

RESULTS

Three potential OCTA parameters including vessel density of the nasal and temporal perifovea in the superficial capillary plexus and vessel density of the inferior parafovea in the deep capillary plexus were further selected as independent retinal vasculature predictors. Model clinical electrocardiogram (ECG) OCTA (clinical variables＋ECG＋OCTA) was presented as the individual prediction nomogram, with good discrimination (AUC of 0.942 [95% CI, 0.923-0.961] and 0.897 [95% CI, 0.861-0.933] in the training and held-out validation sets, respectively) and good calibration. Decision curve analysis indicated the clinical applicability of this retinal vasculature nomogram.

CONCLUSIONS

The presented retinal vasculature nomogram based on individual probability can accurately identify the presence of CAD, which could improve patient selection and diagnostic yield of aggressive testing before determining a diagnosis.

Coronary calcium scoring as first-line test to detect and exclude coronary artery disease in patients presenting to the general practitioner with stable chest pain: protocol of the cluster-randomised CONCRETE trial

INTRODUCTION

Identifying and excluding coronary artery disease (CAD) in patients with atypical angina pectoris (AP) and non-specific thoracic complaints is a challenge for general practitioners (GPs). A diagnostic and prognostic tool could help GPs in determining the likelihood of CAD and guide patient management. Studies in outpatient settings have shown that the CT-based coronary calcium score (CCS) has high accuracy for diagnosis and exclusion of CAD. However, the CT CCS test has not been tested in a primary care setting. In the COroNary Calcium scoring as fiRst-linE Test to dEtect and exclude coronary artery disease in GPs patients with stable chest pain (CONCRETE) study, the impact of direct access of GPs to CT CCS will be investigated. We hypothesise that this will allow for early diagnosis of CAD and treatment, more efficient referral to the cardiologist and a reduction of healthcare-related costs.

METHODS AND ANALYSIS

CONCRETE is a pragmatic multicentre trial with a cluster randomised design, in which direct GP access to the CT CCS test is compared with standard of care. In both arms, at least 40 GP offices, and circa 800 patients with atypical AP and non-specific thoracic complaints will be included. To determine the increase in detection and treatment rate of CAD in GP offices, the CVRM registration rate is derived from the GPs electronic registration system. Individual patients' data regarding cardiovascular risk factors, expressed chest pain complaints, quality of life, downstream testing and CAD diagnosis will be collected through questionnaires and the electronic GP dossier.

ETHICS AND DISSEMINATION

CONCRETE has been approved by the Medical Ethical Committee of the University Medical Center of Groningen.

TRIAL REGISTRATION NUMBER

NTR 7475; Pre-results.

Long-Term Cardiovascular Risk and Management of Patients Recorded in Primary Care With Unattributed Chest Pain: An Electronic Health Record Study

Background Most adults presenting with chest pain will not receive a diagnosis and be recorded with unattributed chest pain. The objective was to assess if they have increased risk of cardiovascular disease compared with those with noncoronary chest pain and determine whether investigations and interventions are targeted at those at highest risk. Methods and Results We used records from general practices in England linked to hospitalization and mortality information. The study population included patients aged 18 years or over with a new record of chest pain with a noncoronary cause or unattributed between 2002 and 2018, and no cardiovascular disease recorded up to 6 months (diagnostic window) afterward. We compared risk of a future cardiovascular event by type of chest pain, adjusting for cardiovascular risk factors and alternative explanations for chest pain. We determined prevalence of cardiac diagnostic investigations and preventative medication during the diagnostic window in patients with estimated cardiovascular risk ≥10%. There were 375 240 patients with unattributed chest pain (245 329 noncoronary chest pain). There was an increased risk of cardiovascular events for patients with unattributed chest pain, highest in the first year (hazard ratio, 1.25 [95% CI, 1.21-1.29]), persistent up to 10 years. Patients with unattributed chest pain had consistently increased risk of myocardial infarction over time but no increased risk of stroke. Thirty percent of patients at higher risk were prescribed lipid-lowering medication. Conclusions Patients presenting to primary care with unattributed chest pain are at increased risk of cardiovascular events. Primary prevention to reduce cardiovascular events appears suboptimal in those at higher risk.

Improving Awareness Could Transform Outcomes in Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 1]

STUDY DESIGN

Literature Review (Narrative).

OBJECTIVE

To introduce the number one research priority for Degenerative Cervical Myelopathy (DCM): Raising Awareness.

METHODS

Raising awareness has been recognized by AO Spine RECODE-DCM as the number one research priority. This article reviews the evidence that awareness is low, the potential drivers, and why this must be addressed. Case studies of success from other diseases are also reviewed, drawing potential parallels and opportunities for DCM.

RESULTS

DCM may affect as many as 1 in 50 adults, yet few will receive a diagnosis and those that do will wait many years for it. This leads to poorer outcomes from surgery and greater disability. DCM is rarely featured in healthcare professional training programs and has received relatively little research funding (<2% of Amyotrophic Lateral Sclerosis or Multiple Sclerosis over the last 25 years). The transformation of stroke and acute coronary syndrome services, from a position of best supportive care with occasional surgery over 50 years ago, to avoidable disability today, represents transferable examples of success and potential opportunities for DCM. Central to this is raising awareness.

CONCLUSION

Despite the devastating burden on the patient, recognition across research, clinical practice, and healthcare policy are limited. DCM represents a significant unmet need that must become an international public health priority.

Incremental value of QT interval for the prediction of obstructive coronary artery disease in patients with chest pain

Identification of obstructive coronary artery disease (OCAD) in patients with chest pain is a clinical challenge. The value of corrected QT interval (QTc) for the prediction of OCAD has yet to be established. We consecutively enrolled 1741 patients with suspected angina. The presence of obstructive OCAD was defined as ≥ 50% diameter stenosis by coronary angiography. The pre-test probability was evaluated by combining QTc prolongation with the CAD Consortium clinical score (CAD2) and the updated Diamond-Forrester (UDF) score. OCAD was detected in 661 patients (38.0%). QTc was longer in patients with OCAD compared with those without OCAD (444 ± 34 vs. 429 ± 28 ms, p < 0.001). QTc was increased by the severity of OCAD (P < 0.001). QTc prolongation was associated with OCAD (odds ratio (OR), 2.27; 95% confidence interval (CI), 1.81–2.85). With QTc, the C-statistics increased significantly from 0.68 (95% CI 0.66–0.71) to 0.76 (95% CI 0.74–0.78) in the CAD2 and from 0.64 (95% CI 0.62–0.67) to 0.74 (95% CI 0.72–0.77) in the UDF score, respectively. QT prolongation predicted the presence of OCAD and the QTc improved model performance to predict OCAD compared with CAD2 or UDF scores in patients with suspected angina.

Why health anxiety needs to be recognised in hospital practice

Health anxiety, formerly part of hypochondriasis, but now reformulated as excessive concern about health and, by extension, illness, comprises a large proportion of consultations in hospital practice. For too long it has been ignored in practice and not formally treated. This belief is no longer tenable, and in the last few years a number of easily administered psychological treatments have shown consistent benefit that help patients, practitioners and planners of services. A stepped care approach in which physicians and nurses are first helped to identify health anxiety, explain its significance to patients and then, if necessary, administer these treatments in the clinical setting without referral to psychiatric services, is recommended as a way forward. This approach should be embraced in secondary care.

Comparison of two strategies in a chest pain unit: stress echocardiography and multidetector computed tomography

INTRODUCTION AND OBJECTIVES

This study aimed to compare stress echocardiography (SE) and multidetector computed tomography (MCT) in patients admitted to a chest pain unit to detect acute coronary syndrome (ACS).

METHODS

A total of 203 patients with ≥ 1 cardiovascular risk factor, no ischemic electrocardiogram changes and negative biomarkers were randomized to SE (n=103) or MTC (n=100). The primary endpoint was a combination of hard events (death and nonfatal myocardial infarction), revascularizations, and readmissions during follow-up. The secondary endpoint was the cost of the 2 strategies.

RESULTS

Invasive angiography was performed in 61 patients (34 [33%] in the SE group and in 27 [27%] in the MCT group, P=.15). A final diagnosis of ACS was made in 53 patients (88% vs 85%, P=.35). There were no significant differences between groups in the primary endpoint (42% vs 41%, P=.91), or in hard events (5% vs 7%, P=.42). There were no significant differences in overall cost, but costs were lower in patients with negative SE than in those with negative MCT (€557 vs €706, P <.02).

CONCLUSIONS

No significant differences were found in efficacy and safety for the stratification of patients with a low to moderate probability of ACS admitted to a chest pain unit. The cost of the 2 strategies was similar, but cost was significantly lower for SE on comparison of negative studies.

Utilization of diagnostic resources and costs in patients with suspected cardiac chest pain

AIMS

Non-acute chest pain is a common complaint and can be caused by various conditions. With the rising healthcare expenditures of today, it is necessary to use our healthcare resources effectively. This study aims to give insight into the diagnostic effort and costs for patients with non-acute chest pain.

METHODS AND RESULTS

Financial data of patients without a cardiac history from 4 hospitals (January 2012-October 2018), who were registered with the national diagnostic code 'No cardiac pathology' (ICD-10 Z13.6), 'Chest wall syndrome' (ICD-10 R07.4) or 'stable angina pectoris' (ICD-10 I20.9) were extracted. In total, 74.091 patients were included for analysis and divided into the following final diagnosis groups: No cardiac pathology: N = 19.688 (age 53±18), 46% male), Chest wall syndrome: N = 40.858 (age 56±15), 45% male), and stable angina pectoris: N = 13.545 (age 67±11), 61% male). A total of approximately €142,7 million was spent during diagnostic work-up. The total expenditure during diagnostic effort was €1.97, €8.13, and €10.7 million respectively for no cardiac pathology, chest wall syndrome, and stable AP per year. After 8 years follow up ≥ 95% of the patients diagnosed with no cardiac pathology or chest wall syndrome had an (cardiac) ischemic free survival.

CONCLUSION

The diagnostic expenditure and clinical effort to ascertain non-cardiac chest pain is high. We should define what we as society find acceptable as 'assurance costs' with an increasing pressure on the healthcare system and costs.

The patient pathway in cardiovascular care: A position paper from the International Pharmacists for Anticoagulation Care Taskforce (iPACT)

BACKGROUND

This position paper highlights the opportunistic integral role of the pharmacist across the patient pathway utilizing cardiovascular care as an example. The paper aims to highlight the potential roles that pharmacists worldwide can have (or already have) to provide efficient patient care in the context of interprofessional collaboration.

METHODS

It results from a literature review and experts seeking advice to identify existing interventions and potential innovative interventions. We developed a conceptual framework highlighting seven critical phases in the patient pathway and for each of those listed some of the initiatives identified by our experts worldwide.

RESULTS

Existing pharmacists' interventions in each of these phases have been identified globally. Various examples in the area of prevention and self-management were found to exist for long; the contribution for early detection and subsequently to timely diagnosis were also quite clear; integration of care was perhaps one of the areas needing greater development, although interventions in secondary care were also quite common. Tertiary care and end of life interventions were found to often be left for other healthcare professionals.

CONCLUSION

On the basis of the findings, we can argue that much has been done but globally consider that pharmacists are still an untapped resource potentially useful for improved patient care.

Clinical outcomes of patients discharged from the Rapid Access Chest Pain Clinic with non-anginal chest pain: A retrospective cohort study

BACKGROUND

The Rapid Access Chest Pain Clinic (RACPC) has become an important means of assessing patients who present with ischaemic or ischaemia-like symptoms of recent onset. Observations have shown that up to 70% are discharged with a diagnosis of non-anginal chest pain (NACP) and accordingly "reassured". This study aims to describe the actual clinical outcomes of this cohort of patients discharged from the RACPC.

METHODS

We undertook a single centre retrospective cohort study at a tertiary cardiac hospital. The outcomes of unselected patients diagnosed with NACP and discharged from the RACPC between April 2010 and March 2013 at University Hospitals of Leicester (UHL) were recorded. Re-referrals to cardiology outpatient clinic and emergency hospital admissions for cardiovascular disease within 6 months, and the mortality rate at 12 months, were determined.

RESULTS

7066 patients were seen in the UHL RACPC during the 36-month period. 3253 (46.0%) were diagnosed with NACP and discharged. 7 (0.2%) were diagnosed with coronary artery disease (CAD) and 8 (0.25%) cases of acute coronary syndrome (ACS) identified during the review period. 11 (0.3%) patients died within 12 months of discharge from RACPC. No deaths were attributable to CAD.

CONCLUSIONS

Comprehensive assessment using risk-stratification criteria in a nurse practitioner-led RACPC can accurately identify patients who are at low-risk for subsequent CAD. Despite contemporary National Institute for Health and Care Excellence (NICE) guidelines that shift focus away from a clinical judgement based approach, this strategy appears to robustly predict favourable outcomes in patients diagnosed with NACP.

Is Physiologic Stress Test with Imaging Comparable to Anatomic Examination of Coronary Arteries by Coronary Computed Tomography Angiography to Investigate Coronary Artery Disease? - A Systematic Review and Meta-Analysis

Objective Coronary computed tomography angiography (CCTA) is a noninvasive diagnostic modality that remains underutilized compared to functional stress testing (ST) for investigating coronary artery disease (CAD). Several patients are misdiagnosed with noncardiac chest pain (CP) that eventually die from a cardiovascular event in subsequent years. We compared CCTA to ST to investigate CP. Methods We searched MEDLINE, PubMed, Cochrane Library, and Embase from January 1, 2007 to July 1, 2018 for randomized controlled trials (RCTs) comparing CCTA to ST in patients who presented with acute or stable CP. We used Review Manager (RevMan) [Computer program] Version 5.3 (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014) for review and analysis. Results We included 16 RCTs enrolling 21,210 patients; there were more patients with hyperlipidemia and older patients in the ST arm compared to the CCTA arm. There was no difference in mortality: 103 in the CCTA arm vs. 110 in the ST arm (risk ratio [RR] = 0.93, 95% confidence interval [CI] = 0.71-1.21, P = .58, and I² = 0%). A significant reduction was seen in myocardial infarctions (MIs) after CCTA compared to ST: 115 vs. 156 (RR = 0.71, CI = 0.56-0.91, P < .006, I²=0%). On subgroup analysis, the CCTA arm had fewer MIs vs. the ST with imaging subgroup (RR = 0.70, CI = 0.54-0.89, P = .004, I² = 0%) and stable CP subgroup (RR = 0.66, CI = 0.50-0.88, P = .004, I² = 0%). The CCTA arm showed significantly higher invasive coronary angiograms and revascularizations and significantly reduced follow-up testing and recurrent hospital visits. A trend towards increased unstable anginas was seen in the CCTA arm. Conclusions Our analysis showed a significant reduction in downstream MIs, hospital visits, and follow-up testing when CCTA is used to investigate CAD with no difference in mortality.

UK perspective on the changing landscape of non-invasive cardiac testing

Objective

To document UK rates of exercise treadmill testing, functional stress testing and CT coronary angiography (CTCA). Specific aims were to determine how rates have changed in the context of changing guideline recommendations within the UK and to identify regional inequalities in the utilisation of testing modalities. Secondary objectives were to compare these trends with national data on revascularisation.

Methods

159 acute National Health Service trusts were served Freedom of Information (FOI) requests to provide total numbers of CTCA and functional imaging tests for each financial year from 2011–2012 to 2016–2017.

Results

The FOI requests yielded data from 88% of Trusts, increasing from 81.9% in 2011–2012% to 92.1% in 2016–2017. Exercise treadmill tests (ETTs) were performed by over 97% of Trusts. ETT was the most commonly performed diagnostic test in the UK across the study period despite declining by 8.4%. Utilisation of non-invasive stress imaging tests increased by 80.9% during the same period. Myocardial perfusion scintigraphy and stress echocardiography increased by 25.8% and 73.9%, respectively. The 268% increase in CTCA scans was yet greater. Trends in test utilisation during the study period showed important regional differences between devolved nations. Comparably, only small changes in rates of invasive coronary angiography and revascularisation have been reported during the study period.

Conclusion

Non-invasive imaging in UK Trusts has increased substantially since 2010 with only a small decline in use of the ETT and minimal changes in rates of invasive coronary angiography and revascularisation in the same time period.

Current approach to the diagnosis of atherosclerotic coronary artery disease: more questions than answers

Despite its commonality in routine clinical practice, the approach to a diagnosis of atherosclerotic coronary artery disease remains complex and, in part, contentious. The traditional dogma linking ischaemia to hard clinical outcomes has been questioned and reframed over the years; rather than being a predictor of hard clinical outcomes, the degree of ischaemia may simply be a marker of atherosclerotic disease burden. A renewed interest in the imaging of plaque burden has spawned the contemporary role of CT imaging for not only diagnosis and prognosis, but also for dictating downstream management. As the technology develops and evidence expands, decisions on investigative modalities remain centred around patient factors, local availability, test performance and cost. This review summarizes the available methods for diagnosis in the symptomatic patient and provides an overview of the current evidence behind functional and anatomical approaches.

Hospitalised patients with unexplained chest pain: incidence and prognosis

BACKGROUND

The prognosis of unexplained chest pain patients provides valuable information for evaluation of health services.

OBJECTIVE

To examine prognosis of unexplained chest pain.

METHODS

Using data from in- and outpatient hospital visits in Norway of patients discharged with a main diagnosis of unexplained chest pain (ICD-10: R072-R074) in 2010-2012, the 1-year incidence of coronary heart disease (CHD), any cardio-vascular disease (CVD) and mortality was evaluated. Cases with prior 2-year history of CVD or chest pain were excluded. Cox proportional hazards evaluated outcomes by patient characteristics and standardized mortality ratios evaluated observed versus expected mortality.

RESULTS

Of 59 569 patients identified (20-89 years of age), the majority (86%) were referred to hospital by out-of-hours emergency care centres. Subsequent CHD was noted for 12.5%, 19.5% and 25.0% of men and 7.2%, 11.0%, 14.0% of women aged 45-64, 65-74 and 75-89 years, respectively. The per cent of deaths attributed to CVD were greatest within the first 2 months of postdischarge. Total mortality rates (per 1000 person-years) were 6.6 in men and 4.7 in women aged 45-64 and 69.2 in men and 39.5 in women aged 75-89 years. Relative to the general population, mortality was 53% and 45% higher for men and women under 65 years of age, respectively, attributed primarily to non-CVD causes.

CONCLUSION

Patients in Norway discharged with unexplained chest pain are an at-risk group in terms of incident CHD, any CVD and mortality, including non-CVD mortality during the first-year postdischarge. The results suggest that unexplained chest pain patients may benefit from greater healthcare coordination between medical disciplines.

Guiding Therapy by Coronary CT Angiography Improves Outcomes in Patients With Stable Chest Pain

BACKGROUND

Within the SCOT-HEART (Scottish COmputed Tomography of the HEART Trial) trial of patients with stable chest pain, the use of coronary computed tomography angiography (CTA) reduced the rate of death from coronary heart disease or nonfatal myocardial infarction (primary endpoint).

OBJECTIVES

This study sought to assess the consistency and mechanisms of the 5-year reduction in this endpoint.

METHODS

In this open-label trial, 4,146 participants were randomized to standard care alone or standard care plus coronary CTA. This study explored the primary endpoint by symptoms, diagnosis, coronary revascularizations, and preventative therapies.

RESULTS

Event reductions were consistent across symptom and risk categories (p = NS for interactions). In patients who were not diagnosed with angina due to coronary heart disease, coronary CTA was associated with a lower primary endpoint incidence rate (0.23; 95% confidence interval [CI]: 0.13 to 0.35 vs. 0.59; 95% CI: 0.42 to 0.80 per 100 patient-years; p < 0.001). In those who had undergone coronary CTA, rates of coronary revascularization were higher in the first year (hazard ratio [HR]: 1.21; 95% CI: 1.01 to 1.46; p = 0.042) but lower beyond 1 year (HR: 0.59; 95% CI: 0.38 to 0.90; p = 0.015). Patients assigned to coronary CTA had higher rates of preventative therapies throughout follow-up (p < 0.001 for all), with rates highest in those with CT-defined coronary artery disease. Modeling studies demonstrated the plausibility of the observed effect size.

CONCLUSIONS

The beneficial effect of coronary CTA on outcomes is consistent across subgroups with plausible underlying mechanisms. Coronary CTA improves coronary heart disease outcomes by enabling better targeting of preventative treatments to those with coronary artery disease. (Scottish COmputed Tomography of the HEART Trial [SCOT-HEART]; NCT01149590).

Computed tomography coronary angiography vs. standard diagnostic procedure for the diagnosis of angina due to coronary heart disease: A cross-sectional study

Patients with episodes of angina are likely to experience future cardiac events and benefit from a revascularization procedure. Conventional invasive coronary angiography is a well-established and reliable method for the detection of angina, but it has a risk of complications and false-negative diagnosis. The objective of the present study was to assess the utility of computed tomography coronary angiography (CTCA) in the diagnosis of angina due to coronary heart disease. A total of 2,426 patients with chest pain referred to the rapid access chest pain clinic of Beijing Anzhen Hospital, Capital Medical University (Beijing, P.R. China) between 18 January 2016 and 1 December 2017 were included in the present cross-sectional study. All patients were subjected to evaluation of symptoms, blood tests, 12-lead electrocardiogram (ECG), exercise ECG, coronary artery calcium scoring and CTCA. The cost of the diagnosis of angina was determined for each individual method. In total, 776 (32%) and 1,420 (58%) of patients were identified to be abnormal on clinical assessment and CTCA, respectively. Exercise ECG results were not correlated with the interpretation of CTCA (r=0.8511). The working area of the angina due to coronary heart disease detected at one time by the different diagnostic procedures was in the order of ECG <clinical assessment <exercise ECG <coronary artery calcium scoring <CTCA. The cost of the 'standard diagnostic procedure (clinical assessments, ECG, exercise ECG)' was 15,452±806 ¥/patient and that of CTCA was 12,546±612 ¥/patient. CTCA had a higher sensitivity for the diagnosis of angina due to coronary heart disease and the cost was lower than that of the 'standard diagnostic procedure' (level of evidence: 3). The current study was registered at the Research Registry on 11th January 2016 (trial no. researchregistry4232).

The prevalence of panic disorder and its related factor in hospitalized patients with chest pain and normal angiography

BACKGROUND

Chest pain is one of the common causes for referrals to cardiologists, 50% of which have no-cardiac origin. The occurrence of chest pains is among the most important factors responsible for psychological disorders. This study aimed to determine the prevalence of panic disorder and its related factor in hospitalized patients with chest pain and normal angiography.

MATERIALS AND METHODS

In a cross-sectional study, 144 patients who referred to Emam Ali Cardiac Hospital of Kermanshah because of chest pain in 2013 and had a normal angiography during admission were selected using census sampling method. The statistical indicators of Chi-square and logistic regression were applied.

RESULTS

From 144 patients with atypical chest pain, 95 were male (66%) and 49 were female (34%). Overall, 41 patients met the criteria for panic diagnosis and thus, the prevalence of panic attacks among patients with atypical chest pain was calculated as 28.5%. The results of multiple logistic regression analysis showed that female gender, early age, and the being single were among the predictive factors for the existence of panic disorder in patients with atypical chest pain and normal angiography (P < 0.001).

CONCLUSIONS

Given the high prevalence of panic disorder in patients hospitalized for chest pain with normal angiography, it is recommended to consider the importance of paying attention to this disorder and identifying patients and referring them to professional psychiatrists.

Poor performance of historical prediction models in patients investigated for chest pain: a prospective single centre, head-to-head comparison in a large cohort of patients

BACKGROUND

An optimal investigation strategy for patients with suspected angina pectoris (AP) remains elusive. Present guidelines use the Duke Clinical Score (DCS) or the Diamond-Forrester (DF) model to compute the likelihood of coronary artery disease (CAD). This prospective study of patients referred to a chest pain clinic compares the relative values of these two historical models and of pain characteristics only to predict the presence of CAD.

PATIENTS AND METHODS

Overall, 1376 patients reviewed in a chest pain clinic were assigned to five CAD likelihood groups (<10, 10-29, 30-60, 61-90 and >90%) using DCS and to three CAD likelihood groups (<15, 15-85 and >85%) using the DF model. Patients were diagnosed with CAD when they had either obstructive (>70%) coronary stenoses or a positive functional test.

RESULTS

In all, 652 (47%) patients had nonanginal CP, 412 (30%) patients had atypical AP and 312 (23%) had typical AP. Four hundred seventeen (30%) patients were not investigated for CAD because of nonanginal symptoms and/or low CAD probability. The actual CAD prevalence was 21% versus a DCS predicted one of 51% and a DF model predicted one of 38% (P<0.001). Both models had modest predictive abilities with areas under the curve of of 0.695 and 0.693 and did not show useful clinical superiority over a prediction model using pain characteristics only (area under the curve: 0.65).

CONCLUSION

CAD prevalence in patients referred for suspected AP is significantly lower than expected by using historical prediction models. The use of risk factors profile and demographics in addition to symptoms characteristics does not improve diagnostic accuracy.

Validity of inducible ischaemia as a surrogate for adverse outcomes in stable coronary artery disease

Regional myocardial ischaemia is commonly expressed as exertional angina in patients with stable coronary artery disease (CAD). It also associates with prognosis, risk tending to increase with the severity of ischaemia. The validity of myocardial ischaemia as a surrogate for adverse clinical outcomes, however, has not been well established. Thus, in cohort studies, ischaemia testing has failed to influence rates of myocardial infarction and coronary death. Moreover, in clinical studies, pharmacological and interventional treatments that are effective in correcting ischaemia have rarely been shown to reduce cardiovascular (CV) risk. This contrasts with statins and other anti-inflammatory drugs that have no direct effect on ischaemia but improve CV outcomes by modifying the atherothrombotic disease process. Despite this, and with little evidence of patient benefit, stress testing is commonly used during the follow-up of patients with stable CAD when the demonstration of ischaemic change may be seen as a target for treatment, independently of symptomatic status. Substitution of a symptom-driven management strategy has the potential to reduce rates of non-invasive stress testing, unnecessary downstream revascularisation procedures and use of valuable resources in patients with stable CAD without adverse consequences for CV risk.

Radical changes to the investigation of stable chest pain following the 2016 NICE update

The 2016 National Institute for Health and Care Excellence (NICE) guidelines mark a radical change in the diagnosis of patients with stable chest pain. Quantitative assessments of the disease probability are no longer considered necessary to determine the need and type of diagnostic testing. Instead, the recommendation is for no diagnostic test if the chest pain is judged to be "non-anginal" and CT coronary angiography (CTCA) in patients with "typical" or "atypical" chest pain. The new emphasis on anatomical, rather than functional testing is driven by the accuracy, safety and cost effectiveness of the different investigations as evaluated by NICE. Despite inevitable resource implications NICE calculates that annual savings will be significant.

Outcomes of non-invasive diagnostic modalities for the detection of coronary artery disease: network meta-analysis of diagnostic randomised controlled trials

OBJECTIVE

To evaluate differences in downstream testing, coronary revascularisation, and clinical outcomes following non-invasive diagnostic modalities used to detect coronary artery disease.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

Medline, Medline in process, Embase, Cochrane Library for clinical trials, PubMed, Web of Science, SCOPUS, WHO International Clinical Trials Registry Platform, and Clinicaltrials.gov.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Diagnostic randomised controlled trials comparing non-invasive diagnostic modalities in patients presenting with symptoms suggestive of low risk acute coronary syndrome or stable coronary artery disease.

DATA SYNTHESIS

A random effects network meta-analysis synthesised available evidence from trials evaluating the effect of non-invasive diagnostic modalities on downstream testing and patient oriented outcomes in patients with suspected coronary artery disease. Modalities included exercise electrocardiograms, stress echocardiography, single photon emission computed tomography-myocardial perfusion imaging, real time myocardial contrast echocardiography, coronary computed tomographic angiography, and cardiovascular magnetic resonance. Unpublished outcome data were obtained from 11 trials.

RESULTS

18 trials of patients with low risk acute coronary syndrome (n=11 329) and 12 trials of those with suspected stable coronary artery disease (n=22 062) were included. Among patients with low risk acute coronary syndrome, stress echocardiography, cardiovascular magnetic resonance, and exercise electrocardiograms resulted in fewer invasive referrals for coronary angiography than coronary computed tomographic angiography (odds ratio 0.28 (95% confidence interval 0.14 to 0.57), 0.32 (0.15 to 0.71), and 0.53 (0.28 to 1.00), respectively). There was no effect on the subsequent risk of myocardial infarction, but estimates were imprecise. Heterogeneity and inconsistency were low. In patients with suspected stable coronary artery disease, an initial diagnostic strategy of stress echocardiography or single photon emission computed tomography-myocardial perfusion imaging resulted in fewer downstream tests than coronary computed tomographic angiography (0.24 (0.08 to 0.74) and 0.57 (0.37 to 0.87), respectively). However, exercise electrocardiograms yielded the highest downstream testing rate. Estimates for death and myocardial infarction were imprecise without clear discrimination between strategies.

CONCLUSIONS

For patients with low risk acute coronary syndrome, an initial diagnostic strategy of stress echocardiography or cardiovascular magnetic resonance is associated with fewer referrals for invasive coronary angiography and revascularisation procedures than non-invasive anatomical testing, without apparent impact on the future risk of myocardial infarction. For suspected stable coronary artery disease, there was no clear discrimination between diagnostic strategies regarding the subsequent need for invasive coronary angiography, and differences in the risk of myocardial infarction cannot be ruled out.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registry no CRD42016049442.

High-Sensitivity Cardiac Troponin I and the Diagnosis of Coronary Artery Disease in Patients With Suspected Angina Pectoris

BACKGROUND

We determined whether high-sensitivity cardiac troponin I can improve the estimation of the pretest probability for obstructive coronary artery disease (CAD) in patients with suspected stable angina.

METHODS AND RESULTS

In a prespecified substudy of the SCOT-HEART trial (Scottish Computed Tomography of the Heart), plasma cardiac troponin was measured using a high-sensitivity single-molecule counting assay in 943 adults with suspected stable angina who had undergone coronary computed tomographic angiography. Rates of obstructive CAD were compared with the pretest probability determined by the CAD Consortium risk model with and without cardiac troponin concentrations. External validation was undertaken in an independent study population from Denmark comprising 487 patients with suspected stable angina. Higher cardiac troponin concentrations were associated with obstructive CAD with a 5-fold increase across quintiles (9%-48%; P<0.001) independent of known cardiovascular risk factors (odds ratio, 1.35; 95% confidence interval, 1.25-1.46 per doubling of troponin). Cardiac troponin concentrations improved the discrimination and calibration of the CAD Consortium model for identifying obstructive CAD (C statistic, 0.788-0.800; P=0.004; χ2=16.8 [P=0.032] to 14.3 [P=0.074]). The updated model also improved classification of the American College of Cardiology/American Heart Association pretest probability risk categories (net reclassification improvement, 0.062; 95% confidence interval, 0.035-0.089). The revised model achieved similar improvements in discrimination and calibration when applied in the external validation cohort.

CONCLUSIONS

High-sensitivity cardiac troponin I concentration is an independent predictor of obstructive CAD in patients with suspected stable angina. Use of this test may improve the selection of patients for further investigation and treatment.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01149590.

Characteristics and Outcomes of Patients Discharged Home from an Emergency Department with AKI

BACKGROUND AND OBJECTIVES

Patients discharged home from an emergency department with AKI are not well described. This study describes their characteristics and outcomes and compares these outcomes to two referent groups.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a population-based retrospective cohort study in Ontario, Canada from 2003 to 2012 of 6346 patients aged ≥40 years who were discharged from the emergency department with AKI (defined using serum creatinine values). We analyzed the risk of all-cause mortality, receipt of acute dialysis, and hospitalization within 30 days after discharge. We used propensity score methods to compare all-cause mortality to two referent groups. We matched 4379 discharged patients to 4379 patients who were hospitalized from the emergency department with similar AKI stage. We also matched 6188 discharged patients to 6188 patients who were discharged home from the emergency department with no AKI.

RESULTS

There were 6346 emergency department discharges with AKI. The mean age was 69 years and 6012 (95%) had stage 1, 290 (5%) had stage 2, and 44 (0.7%) had stage 3 AKI. Within 30 days, 149 (2%) (AKI stage 1: 127 [2%]; stage 2: 15 [5%]; stage 3: seven [16%]) died, 22 (0.3%) received acute dialysis, and 1032 (16%) were hospitalized. An emergency department discharge versus hospitalization with AKI was associated with lower mortality (3% versus 12%; relative risk, 0.3; 95% confidence interval, 0.2 to 0.3). An emergency department discharge with AKI versus no AKI was associated with higher mortality (2% versus 1%; relative risk, 1.6; 95% confidence interval, 1.2 to 2.0).

CONCLUSIONS

Patients discharged home from the emergency department with AKI are at risk of poor 30-day outcomes. A better understanding of care in this at-risk population is warranted, as are testing strategies to improve care.

Clinical and cost-effectiveness of adapted cognitive behaviour therapy for non-cardiac chest pain: a multicentre, randomised controlled trial

OBJECTIVE

To investigate the cost-effectiveness of a modified form of cognitive behavioural therapy (CBT) for recurrent non-cardiac chest pain.

METHODS

We tested the effectiveness and cost-effectiveness of a modified form of CBT for chest pain (CBT-CP)(4-10 sessions) in patients who attended cardiology clinics or emergency medical services repeatedly. Patients were randomised using a remote web-based system to CBT-CP or to standard care in the clinic. Assessments were made at baseline and at 6 months and 12 months. The primary outcome was the change in the Health Anxiety Inventory Score at 6 months. Other clinical measures, social functioning, quality of life and costs of services were also recorded.

RESULTS

Sixty-eight patients were randomised with low attrition rates at 6 months and 12 months with 81% of all possible assessments completed at 6 months and 12 months. Although there were no significant group differences between any of the outcome measures at either 6 months or 12 months, patients receiving CBT-CP had between two and three times fewer hospital bed days, outpatient appointments, and A&E attendances than those allocated to standard care and total costs per patient were £1496.49 lower, though the differences in costs were not significant. There was a small non-significant gain in quality adjusted life years in those allocated to CBT-CP compared with standard care (0.76 vs 0.74).

CONCLUSIONS

It is concluded that CBT-CP in the context of current hospital structures is not a viable treatment, but is worthy of further research as a potentially cost-effective treatment for non-cardiac chest pain.

TRIAL REGISTRATION NUMBER

ISRCTN 14711101.

National Institute for Health and Care Excellence updates the stable chest pain guideline with radical changes to the diagnostic paradigm

In the 2016 update of the stable chest pain guideline, the National Institute for Health and Care Excellence (NICE) has made radical changes to the diagnostic paradigm that it-like other international guidelines-had previously placed at the centre of its recommendations. No longer are quantitative assessments of the disease probability considered necessary to determine the need for diagnostic testing and the choice of test. Instead, the recommendation is for no diagnostic testing if chest pain is judged to be 'non-anginal' and CT coronary angiography (CTCA) in patients with 'typical' or 'atypical' chest pain with additional perfusion imaging only if there is uncertainty about the functional significance of coronary lesions. The new emphasis on anatomical-as opposed to functional-testing is driven in large part by cost-effectiveness analysis and despite inevitable resource implications NICE calculates that annual savings for the population of England will be significant. In making CTCA the default diagnostic testing strategy in its updated chest pain guideline, NICE has responded emphatically to calls from trialists for CTCA to have a greater role in the diagnostic pathway of patients with suspected angina.

Prognosis of undiagnosed chest pain: linked electronic health record cohort study

Objective To ascertain long term cardiovascular outcomes in patients whose chest pain remained undiagnosed six months after first presentation.Design Cohort study.Setting UK electronic health record database (CALIBER) linking primary care, secondary care, coronary registry, and death registry information.Participants 172 180 adults aged ≥18 from 223 general practices presenting with a first episode of recorded chest pain, classified from medical records as diagnosed (non-coronary condition or angina) or undiagnosed (cause unattributed) at first consultation between 2002 and 2009 and with no previous record of cardiovascular disease.Main outcome measures Fatal or non-fatal cardiovascular events over 5.5 years' follow-up. Adjustments were made for age, sex, deprivation, body mass index, smoking status, year of index presentation, and previous records of diabetes or hypertension or previous prescriptions for lipid lowering drugs.Results At the index presentation, 72.4% of patients (124 688) did not have a cause attributed for their chest pain; 118 687 (95.2%) of these did not receive any type of cardiovascular diagnosis over the next six months. Only a minority of patients in all three groups (non-coronary 2.0% (769 of 39 232); unattributed 11.7% (14 582 of 124 688); angina 31.5% (2606 of 8260)) had a recorded cardiac diagnostic investigation in the first six months after presentation. The long term incidence of cardiovascular events was higher in those whose chest pain remained unattributed after six months (5126 of 109 628; 4.7%) compared with patients with an initial diagnosis of non-coronary pain (1073 of 36 097; 3.0%) (adjusted hazard ratios for 0.5-1 year after presentation: 1.95, 95% confidence interval 1.66 to 2.31; for 1-3 years: 1.35, 1.23 to 1.48); for 3-5.5 years: 1.21, 1.08 to 1.37). Owing to the larger number of patients in the unattributed group, there were more excess myocardial infarctions in the long term in this group (214 more than expected based on the rate in the non-coronary group) than in the angina group (132 more than expected). Patients who had cardiac diagnostic investigations in the first six months had a higher long term risk of cardiovascular events, regardless of the initial chest pain label. Incidence of unattributed chest pain and angina decreased between 2002 (124 per 10 000 person years and 13 per 10 000 person years, respectively) and 2009 (107 per 10 000 person years and 5 per 10 000 person years, respectively), but the incidence of chest pain attributed to a non-coronary cause remained stable (37-40 per 10 000 person years). Risk of cardiovascular events did not change over time.Conclusions Most patients with first onset chest pain do not have a diagnosis recorded at presentation or in the subsequent six months, including those who undergo cardiac investigations. These patients have an increased risk of cardiovascular events for at least five years. Efforts to better assess and reduce the cardiovascular risk of such patients are warranted.

The Updated NICE Guidelines: Cardiac CT as the First-Line Test for Coronary Artery Disease

Purpose of Review

Cost-effective care pathways are integral to delivering sustainable healthcare programmes. Due to the overestimation of coronary artery disease using traditional risk tables, non-invasive testing has been utilised to improve risk stratification and initiate appropriate management to reduce the dependence on invasive investigations. In line with recent technological improvements, cardiac CT is a modality that offers a detailed anatomical assessment of coronary artery disease comparable to invasive coronary angiography.

Recent Findings

The recent publication of the National Institute for Health and Care Excellences (NICE) Clinical Guideline 95 update assesses the performance and cost utility of different non-invasive imaging strategies in patients presenting with suspected anginal chest pain. The low cost and high sensitivity of cardiac CT makes it the non-invasive test of choice in the evaluation of stable angina. This has now been ratified in national guidelines with NICE recommending cardiac CT as the first-line investigation for all patients presenting with chest pain due to suspected coronary artery disease. Additionally, randomised controlled trials have demonstrated that cardiac CT improves diagnostic certainty when incorporated into chest pain pathways.

Summary

NICE recommend cardiac CT as the first-line test for the evaluation of stable coronary artery disease in chest pain pathways.

Using nationwide ‘big data’ from linked electronic health records to help improve outcomes in cardiovascular diseases: 33 studies using methods from epidemiology, informatics, economics and social science in the ClinicAl disease research using LInked Bespoke studies and Electronic health Records (CALIBER) programme

Background

Electronic health records (EHRs), when linked across primary and secondary care and curated for research use, have the potential to improve our understanding of care quality and outcomes.

Objective

To evaluate new opportunities arising from linked EHRs for improving quality of care and outcomes for patients at risk of or with coronary disease across the patient journey.

Design

Epidemiological cohort, health informatics, health economics and ethnographic approaches were used.

Setting

230 NHS hospitals and 226 general practices in England and Wales.

Participants

Up to 2 million initially healthy adults, 100,000 people with stable coronary artery disease (SCAD) and up to 300,000 patients with acute coronary syndrome.

Main outcome measures

Quality of care, fatal and non-fatal cardiovascular disease (CVD) events.

Data platform and methods

We created a novel research platform [ClinicAl disease research using LInked Bespoke studies and Electronic health Records (CALIBER)] based on linkage of four major sources of EHR data in primary care and national registries. We carried out 33 complementary studies within the CALIBER framework. We developed a web-based clinical decision support system (CDSS) in hospital chest pain clinics. We established a novel consented prognostic clinical cohort of SCAD patients.

Results

CALIBER was successfully established as a valid research platform based on linked EHR data in nearly 2 million adults with > 600 EHR phenotypes implemented on the web portal (seehttps://caliberresearch.org/portal). Despite national guidance, key opportunities for investigation and treatment were missed across the patient journey, resulting in a worse prognosis for patients in the UK compared with patients in health systems in other countries. Our novel, contemporary, high-resolution studies showed heterogeneous associations for CVD risk factors across CVDs. The CDSS did not alter the decision-making behaviour of clinicians in chest pain clinics. Prognostic models using real-world data validly discriminated risk of death and events, and were used in cost-effectiveness decision models.

Conclusions

Emerging ‘big data’ opportunities arising from the linkage of records at different stages of a patient’s journey are vital to the generation of actionable insights into the diagnosis, risk stratification and cost-effective treatment of people at risk of, or with, CVD.

Future work

The vast majority of NHS data remain inaccessible to research and this hampers efforts to improve efficiency and quality of care and to drive innovation. We propose three priority directions for further research. First, there is an urgent need to ‘unlock’ more detailed data within hospitals for the scale of the UK’s 65 million population. Second, there is a need for scaled approaches to using EHRs to design and carry out trials, and interpret the implementation of trial results. Third, large-scale, disease agnostic genetic and biological collections linked to such EHRs are required in order to deliver precision medicine and to innovate discovery.

Study registration

CALIBER studies are registered as follows: study 2 – NCT01569139, study 4 – NCT02176174 and NCT01164371, study 5 – NCT01163513, studies 6 and 7 – NCT01804439, study 8 – NCT02285322, and studies 26–29 – NCT01162187. Optimising the Management of Angina is registered as Current Controlled Trials ISRCTN54381840.

Funding

The National Institute for Health Research (NIHR) Programme Grants for Applied Research programme (RP-PG-0407-10314) (all 33 studies) and additional funding from the Wellcome Trust (study 1), Medical Research Council Partnership grant (study 3), Servier (study 16), NIHR Research Methods Fellowship funding (study 19) and NIHR Research for Patient Benefit (study 33).

Coronary CT Angiography as a Diagnostic and Prognostic Tool: Perspectives from the SCOT-HEART Trial

Coronary artery disease is the leading cause of death worldwide. Many trials to date have investigated the diagnostic accuracy of coronary computed tomography angiography (CCTA) when compared to the gold standard diagnostic test, invasive coronary angiography. However, whether the use of a non-invasive anatomical test, such as CCTA, can translate into improved patient risk stratification, management and outcome has yet to be established. The Scottish COmputed Tomography of the HEART (SCOT-HEART) trial sought to address these questions and determined whether CCTA, when used in addition to standard care, could aid the diagnosis, further investigation and treatment of patients referred to the cardiology clinic with suspected angina due to coronary heart disease. In this trial, CCTA clarified the diagnosis of angina due to coronary heart disease in a quarter of patients and this led to major alterations in treatment and management that appeared to reduce the risk of subsequent coronary heart disease death or non-fatal myocardial infarction. The SCOT-Heart trial has established that CCTA is a valuable diagnostic test in patients with suspected angina pectoris due to coronary heart disease and leads to greater clarity, more focused appropriate treatments and better coronary heart disease outcomes.

Diagnostic Strategies for the Evaluation of Chest Pain: Clinical Implications From SCOT-HEART and PROMISE

SCOT-HEART (Scottish COmputed Tomography of the HEART) and PROMISE (PROspective Multicenter Imaging Study for Evaluation of chest pain) represent the 2 largest and most comprehensive cardiovascular imaging outcome trials in patients with stable chest pain and provide significant insights into patient diagnosis, management, and outcomes. These trials are particularly timely, given the well-recognized knowledge gaps and widespread use of noninvasive imaging. The overall goal of this review is to distill the data generated from these 2 pivotal trials to better inform the practicing clinician in the selection of noninvasive testing for stable chest pain. Similarities and differences between SCOT-HEART and PROMISE are highlighted, and clinical and practical implications are discussed. Both trials show that coronary computed tomography angiography should have a greater role in the diagnostic pathway of patients with stable chest pain.

Prolonged dual antiplatelet therapy in stable coronary disease: comparative observational study of benefits and harms in unselected versus trial populations

OBJECTIVE

 To estimate the potential magnitude in unselected patients of the benefits and harms of prolonged dual antiplatelet therapy after acute myocardial infarction seen in selected patients with high risk characteristics in trials.

DESIGN

 Observational population based cohort study.

SETTING

 PEGASUS-TIMI-54 trial population and CALIBER (ClinicAl research using LInked Bespoke studies and Electronic health Records).

PARTICIPANTS

 7238 patients who survived a year or more after acute myocardial infarction.

INTERVENTIONS

 Prolonged dual antiplatelet therapy after acute myocardial infarction.

MAIN OUTCOME MEASURES

 Recurrent acute myocardial infarction, stroke, or fatal cardiovascular disease. Fatal, severe, or intracranial bleeding.

RESULTS

 1676/7238 (23.1%) patients met trial inclusion and exclusion criteria ("target" population). Compared with the placebo arm in the trial population, in the target population the median age was 12 years higher, there were more women (48.6% v 24.3%), and there was a substantially higher cumulative three year risk of both the primary (benefit) trial endpoint of recurrent acute myocardial infarction, stroke, or fatal cardiovascular disease (18.8% (95% confidence interval 16.3% to 21.8%) v 9.04%) and the primary (harm) endpoint of fatal, severe, or intracranial bleeding (3.0% (2.0% to 4.4%) v 1.26% (TIMI major bleeding)). Application of intention to treat relative risks from the trial (ticagrelor 60 mg daily arm) to CALIBER's target population showed an estimated 101 (95% confidence interval 87 to 117) ischaemic events prevented per 10 000 treated per year and an estimated 75 (50 to 110) excess fatal, severe, or intracranial bleeds caused per 10 000 patients treated per year. Generalisation from CALIBER's target subgroup to all 7238 real world patients who were stable at least one year after acute myocardial infarction showed similar three year risks of ischaemic events (17.2%, 16.0% to 18.5%), with an estimated 92 (86 to 99) events prevented per 10 000 patients treated per year, and similar three year risks of bleeding events (2.3%, 1.8% to 2.9%), with an estimated 58 (45 to 73) events caused per 10 000 patients treated per year.

CONCLUSIONS

 This novel use of primary-secondary care linked electronic health records allows characterisation of "healthy trial participant" effects and confirms the potential absolute benefits and harms of dual antiplatelet therapy in representative patients a year or more after acute myocardial infarction.