Coronary artery disease is one of the greatest health care problems facing the western industrialised nations. Each year in the UK coronary artery disease is responsible for approximately 125 000 deaths, 274 000 non-fatal myocardial infarctions, and 330 000 new presentations of angina.¹ There have been significant advances in coronary disease treatment over the last few years, with improvements in pharmacological therapy, percutaneous coronary intervention, and bypass surgery. It is therefore increasingly important to identify patients who will benefit from these approaches from the large number of people presenting with chest pain. The cost of identifying this group is putting health care systems under severe financial strain as much as the expense of the treatment itself. The importance of this issue was recognised by the UK government with the publication of its National Service Framework (NSF) for coronary heart disease document in 2000, linked to the provision of significant additional funding.²

An extensive body of evidence has accumulated over the last 20 years demonstrating the ability of nuclear cardiology techniques, particularly myocardial perfusion imaging (MPI), to identify and risk stratify patients with coronary artery disease.³ Strategies which involve MPI in the investigation of patients with chest pain have been shown to be cost effective as well as clinically effective.^4–6 MPI is therefore a potentially valuable tool in a resource limited system such as the National Health Service (NHS) in the UK. This article will attempt to define a realistic evidence based role for MPI in UK cardiology and will then review current practice in terms of both the number and quality of investigations performed.

INVESTIGATING THE PATIENT WITH CHEST PAIN

Chest pain is a very common symptom in the general population but in only a minority of patients does coronary disease turn out to be the cause. A careful history will …