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Assessing the Benefit of CT Coronary Angiography versus Exercise Stress Testing in a University Teaching Hospital in Ireland.
Poster Title: Assessing the Benefit of CT Coronary Angiography versus Exercise Stress Testing in a University Teaching Hospital in Ireland.
Submitted on 30 Oct 2020
Author(s): James Mannion, David Cotter, Colin Gorry, David Jackson, Pat O'Callaghan, Patrick Owens
Affiliations: Cardiology Department, University Hospital Waterford
Poster Views: 30
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Poster Information
Abstract: The European Society of Cardiology (ESC) chronic coronary syndrome guidelines 2019 give class 1.A. recommendation to CT coronary angiography (CTCA) over exercise stress test (EST) to investigate low-intermediate risk chest pain. NICE guidelines also advocate CTCA use when stable angina cannot be excluded by clinical assessment.[1.2] CTCA is not routinely available in many Irish centres. National Health Service (NHS) figures show CTCA providing cost benefit over EST following reduction in invasive coronary angiograms (ICA) and inpatient days.[3] We investigated chest pain admissions in our centre during 2019, to assess the role for CTCA.
613 patients were identified. A randomized representative sample, 106 patients (17%), were risk stratified via the HeartScore.[4] Typicality of pain, investigations, and admission duration were analysed. STEMI patients were excluded, 100 remained.
Patients were categorised as low risk (HeartScore 1-3), intermediate risk (4-6) or high risk (7+). We found a positive relationship between HeartScore and presence of a flow-limiting lesion. Overall, 42 patients had EST, with 9 (21.4%) displaying equivocal results. In the moderate risk category, 23 of 27 patients (85%) who had EST progressed to ICA, with 9 patients (39%) identifying a significant lesion. Mean wait times for inpatient ICA was 6.67 bed-days.
Compared to ICA, EST had a sensitivity of 88.9% (95% C.I. 50.6%-99.4%) and specificity of 40% (95% C.I. 21.8%-61.1%%). This extends wait times for the service and increases costs. CTCA superior positive and negative predictive value[5,6] could lead to significant long term-savings and improved outcomes for this population.
Summary: Evaluation of the sensitivity and specificity of exercise stress testing in a university teaching hospital, where CTCA is not routinely available, to assess the potential benefits of its implementation based on newest ESC and NICE guidelines. References: References
[1] 1. Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. European Heart Journal. 2019;41(3):407-477.
[2] Recommendations | Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis | Guidance | NICE [Internet]. 2020.
[3] Lorenzoni V, Bellelli S, Caselli C, Knuuti J, Underwood S, Neglia D et al. Cost-effectiveness analysis of stand-alone or combined non-invasive imaging tests for the diagnosis of stable coronary artery disease: results from the EVINCI study. The European Journal of Health Economics. 2019;20(9):1437-1449.
[4] HeartScore [Internet]. 2020.
[5] CTCA outperforms ETT in patients with stable chest pain and low-to-intermediate predicted risk. British Journal of Cardiology. 2013.
[6] Rahsepar A, Arbab-Zadeh A. Cardiac CT vs. Stress Testing in Patients with Suspected Coronary Artery
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