19 Do We Investigate Stable Chest Pain Appropriately?

Abstract

Introduction Differentiating chest pain that is caused by coronary artery disease (CAD) versus non-cardiac causes of chest pain is challenging. NICE guidelines recommend diagnosis should be made clinically with, if needed, functional cardiac imaging and invasive coronary angiography (CA). However, international studies reveal a surprising variation in the number of patients with ‘normal’ coronary arteries on elective CA (18.8–59%), potentially due to an overreliance on invasive investigations, inadequate pre-procedural clinical risk assessment and underuse of non-invasive imaging. Aim What proportion of elective CA at Good Hope Hospital (GHH) were ‘normal’ and were they referred appropriately according to the current NICE guidelines? Methods We reviewed 738 coronary angiographies performed between September 2012–September 2013 at GHH. Of these, 377 patients had elective CA for chest pain. Angiogram findings were divided into 3 categories; interventional management. >50% stenosis of any vessel managed medically. 9Normal9 coronary arteries ( We risk stratified patients with ‘normal’ coronary arteries on CA according to the NICE guidelines in order to assess the proportion of inappropriate referrals. Results Of the 377 elective CA for chest pain, 48% (182) had ‘normal’ coronary arteries. Of these, 44% were referred inappropriately according to NICE guidelines. Further analysis of those patients who had normal coronary arteries and were referred inappropriately, revealed that patients had often not received the recommended non-invasive imaging or they were over investigated but under-treated. Conclusion GHH lies within the international parameters for the proportion of ‘normal’ elective CA. Nevertheless, according to NICE guidelines, too many patients have invasive CA unnecessarily at GHH. This in part can be explained by an overreliance on CA and the underuse of functional imaging to diagnose CAD. Furthermore, one could argue that inadequate pre-procedural clinical risk assessment is exposing patients to avoidable risks and wastes NHS resources. However, our findings can also be explained in part by some genuine concerns that cardiologists have with the NICE guidelines on stable chest pain. In particular, the evidence base and practicalities of functional cardiac imaging as well as concern with the idea of managing patients without proven coronary artery disease with lifelong medication. In any case, standardising and improving the referral system in order to adjust the threshold required to proceed for a CA may improve the procedural specificity by reducing the number of ‘normal’ angiograms.