Coronary Artery Disease
Magnitude and consequences of error in coronary angiography interpretation (the ACRE study)

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Abstract

In the routine reporting of coronary angiograms, there are no contemporary estimates of the magnitude and consequences of interobserver variability. We therefore measured the agreement beyond chance between (1) the number of narrowed arteries on an angiographic report extracted from case notes and independent assessments by 2 cardiologists, and (2) actual patient management over an 18-month follow-up period and each cardiologist’s hypothetical management proposal based on abstracted clinical details. Two hundred nine angiograms were randomly selected from 4,121 patients in a prospective study (Appropriateness of Coronary Revascularisation [ACRE study]). The number of narrowed arteries was defined using Coronary Artery Surgery Study (CASS) criteria. For the number of narrowed arteries, cardiologists A and B agreed with the angiographic report in 126 patients (60%, weighted kappa (κ) = 0.64) and 124 patients (59%, weighted κ = 0.63), respectively. In a subset of 92 patients (44%) there was unanimous agreement on the number of narrowed arteries (both cardiologists agreed with the angiographic report). Comparing actual management (34 percutaneous transluminal coronary angioplasty and 39 coronary artery bypass grafting procedures on follow-up) with each of the cardiologist’s management recommendations showed agreement in 150 patients (72%, κ = 0.46) and 154 patients (74%, κ = 0.48) for cardiologists A and B, respectively. These agreements on management improved (p = 0.05) for cardiologist B (but not A) when analysis was confined to the subset of 92 patients, showing agreement in 73 patients (79%, κ = 0.60). Thus, in routine clinical practice, the agreement beyond chance in interpretation of the number of narrowed arteries was good. Disagreements on subsequent patient management arose as a result of, and independent of, errors in angiographic interpretation.

Section snippets

Study group

Patients (n = 209) were randomly selected for inclusion in this study if they satisfied the following criteria: (1) coronary angiography performed between April 1996 and April 1997 at the London Chest Hospital, London, United Kingdom; (2) no previous revascularization (because the angiographic appearances in such patients might bias the reliability estimates); and (3) participation in the ACRE study (n = 4,121). The ACRE study is a prospective cohort of all patients who underwent coronary

Patient characteristics

The 209 patients had a mean age of 58 years (range 23 to 83) and 32% were women. Clinical presentations were chronic stable angina (44%), unstable angina (13%), myocardial infarction (16%), asymptomatic (10%), atypical chest pain (9%), and other (8%). Fifteen percent of patients were diabetic, 36% hypertensive, and 14% were current smokers. Only 11 patients (5%) had a Parsonnet score >18, indicating high operative risk. The sample was representative of the larger ACRE cohort in terms of age,

Discussion

This is the first study of interobserver variability in the interpretation of coronary angiography in routine clinical practice. There was a low magnitude of error (good agreement beyond chance) in the number of narrowed arteries recorded in the case notes compared with independent review by 2 cardiologists who were blinded to clinical details. We investigated the possible consequences of such error by comparing actual patient management with hypothetical management decisions, separately in

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    The ACRE study was established with a grant from East London and the City Health Authority, and subsequently funded by a consortium of health authorities (North Essex, Barking and Havering, Redbridge and Waltham Forest), the North Thames NHS Research and Development program (RFG 258), and the British Heart Foundation (PG/97216), London, United Kingdom.

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