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Dear Editor, Cremer and Nissen have chosen to traduce the National Institute for Health and Care Excellence (NICE) guideline update in their editorial.1 The views they express are inaccurate and biased as summarised in the bulleted comments that follow:
Contrary to the assertion by Cremer and Nissen, the NICE guideline emphasises the importance of a careful history to guide the need for further diagnostic testing.
Nowhere does the NICE guideline state that assessing pretest probability (PTP) of disease is ‘useless’ or that Bayesian analysis should be ‘abandoned’. It merely observes that regardless of age and gender, nearly all patients with atypical or typical chest pain have a PTP of disease between 10% and 90% by Genders’ updated diagnostic model. In all such patients, therefore, non-invasive testing can usefully modify disease probability according to Bayesian principles. Accordingly, NICE recommends testing in all patients with atypical or typical chest pain.
The non-invasive test recommended by NICE is CTCA based on its high diagnostic value compared with other tests and its cost-effectiveness. As discussed in our review, the analysis performed independently by NICE and reported within the guideline identified CTCA as the most cost-effective initial test, consistent with other recent cost-effectiveness work.
Cremer and Nissen are incorrect in stating that ‘universal CTCA cannot be more cost-effective than a strategy that involves no testing in some patients’. NICE health economists included a ‘no-testing’ strategy in the economic model. It should also be recognised that the NICE recommendation is for no testing in patients with a history of non-anginal chest pain. Such patients account for about 40% of chest pain clinic populations.
In their discussion of the exercise, ECG Cremer and Nissen concede that it is ‘inferior to imaging-based tests’. This is why NICE and European guidelines favour imaging-based diagnostic tests. They speculate on the prognostic value of the exercise ECG but do they really believe that definition of the extent and severity of coronary artery disease by CTCA provides less useful prognostic information?
Cremer and Nissen acknowledge that a key benefit of CTCA is its success in identifying patients with obstructive disease at subsequent invasive coronary angiography. Bizarrely, they then consider it ‘alarming’ that CTCA, having successfully identified more patients with obstructive disease, leads to higher rates of revascularisation compared with other tests.
There are other factual errors in Cremer and Nissen’s editorial. For example, they erroneously state that our review identified PLATFORM as a randomised trial. It did not. They go on to state it is ‘incredibly irresponsible’ to recommend widespread use of CT-Fractional Flow Reserve. Again, we did not.
Finally, Cremer and Nissen conclude that the NICE guideline update ‘should have focused on the low event rate achievable with optimal medical therapy and the inability of imaging to modify outcomes for many of these low-risk patients’. Their conclusion seems to confirm a misunderstanding of the guideline’s purpose which was to identify an optimal diagnostic strategy in patients with chest pain not to speculate on how treatment might affect outcomes.
NICE guidelines are evidence-based recommendations produced by an independent national body with experts in systematic review, data analysis and economic modelling. They gather all the credible scientific evidence and employ strategies that take into account the views of patients and national stakeholders to deliver cost-effective guidelines for UK practice. The process is sufficiently rigorous to provide an effective rebuff against the ill-tempered editorial from Cremer and Nissen.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.