Introduction The UK National Institute of Health and Care Excellence (NICE) updated its guidelines on management of chest pain in 2016. NICE now recommend CT coronary angiography (CTCA) as the first line investigation for all new patients presenting with stable chest pain. This is different from the NICE 2010 guidelines which recommended that patients with high pre-test probability of having coronary artery disease (CAD) are referred directly for invasive coronary angiography (ICA). We previously implemented the NICE 2010 guidelines and referred all patients with high probability of CAD for ICA, audited this practice and found a low yield of severe CAD of 30%(1). We have now implemented the NICE 2016 guideline in a district general hospital and evaluated rates of ICA and yield of severe CAD.
Methods We undertook a retrospective search of the local radiology database from January 2017 to June 2018. CTCA reports CAD grade as normal/minimal stenosis, mild (30–50%), moderate (50–70%), or severe (>70%). Subsequent downstream investigations were audited.
Results In total 652 patients underwent CTCA (mean age 55 yrs; 330 male). A total of 65 patients underwent ICA following an interpretable CTCA, with 41 patients found to have severe CAD, a yield of 63%.
Importantly, 34 patients were found to have severe CAD on CTCA, with 30 attending for ICA which confirmed severe CAD in 22, a yield of 73%. 18 patients went on to be revascularised.
58 patients were deemed to have moderate CAD on CTCA, with 37 referred for ICA of which 33 attended and 18 were found to have severe CAD. 18 were referred for imaging stress tests and only one had a positive test. The total yield of severe CAD for this subgroup at ICA was 55%. 17 patients were revascularised.
Finally, a total of 63 patients were deemed to have mild disease, with 2 patients referred for ICA and one found to have severe CAD. The majority of patients (n=462) had normal/minimal CTCA stenosis. There were a total of 36 inconclusive CTCA studies.
Conclusion In patients undergoing ICA following CTCA, the overall yield of severe CAD was 63%. This compares very well with our previous data when we applied the NICE 2010 guidelines, which recommended ICA as first line test for all patients with high likelihood of having CAD, wherein the yield of severe CAD was only 30%.
The yield of severe CAD is likely to improve further with greater utilisation of imaging stress tests as a gatekeeper to ICA in patients with moderate stenosis at CTCA.
1.Rauf A DS, Pierres F, Jackson A, Papamichail N, Pavlidis A, Alfakih A. Current diagnostic yield of invasive coronary angiography at a district general hospital. Br J Cardiol. 2017;24:(4).
Conflict of Interest None
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