Harvey S. Hecht; Leslee Shaw; Y.S. Chandrashekhar; Jeroen J. Bax; Jagat NarulaDISCLOSURES
Eur Heart J. 2019;40(18):1440-1453.
Abstract and Introduction
The 2016 National Institute of Health and Care Excellence clinical guideline for the assessment and diagnosis of chest pain positions coronary computed tomography angiography as the first test for all stable chest pain patients without confirmed coronary artery disease and discards the previous emphasis on calculation of pre-test likelihood recommended in their 2012 edition of the guidelines. On the other hand, the American College of Cardiology Foundation/American Heart Association and the European Society of Cardiology guidelines continue to present the stress testing functional modalities as the tests of choice. The aim of this review is to present, in the form of a debate, the pros and cons of these paradigm changing recommendations, with an emphasis on literature review and projection of future needs, with conclusions to be drawn by the reader.
Introduction: Nice Guidelines for Evaluation of Stable Coronary Disease
The National Institute of Health and Care Excellence (NICE) is the executive non-departmental public body of the Department of Health in the United Kingdom responsible for determination of health care policy for both the English and Welsh National Health Service. The 2016 NICE update for the Chest Pain of Recent Onset: Assessment and Diagnosis Clinical Guideline(Figure 1) was proposed after exhaustive review and analysis of accuracy, outcomes and cost effectiveness, and has since replaced the 2012 version. The guideline positions coronary computed tomography angiography (CCTA) as the first test for all stable chest pain patients without confirmed coronary artery disease (CAD), and (interestingly) discards the previous emphasis on calculation of pre-test likelihood recommended in the 2012 edition of the guidelines. In the penultimate version, the first line investigations were stratified as invasive coronary angiography (ICA) for estimated CAD likelihood of >60–90%, functional imaging for >30–60%, and coronary artery calcium (CAC) scan for estimated CAD likelihood of >10–30%. However, in patients with previously confirmed CAD, functional imaging and maximum endurance exercise treadmill testing (ETT) remain as the recommended first line tests for any change in clinical status or for timely follow-up. The NICE document has further added that fractional flow reserve (FFR) derived from computed tomography angiography (CTA) (FFRCT) should be considered as an option for patients with stable, recent onset chest pain who are offered CTA as part of the NICE pathway on chest pain, and have projected significant cost savings accruing from its utilization.
National Institute of Health and Care Excellence (NICE) guideline for ‘Chest Pain of Recent Onset Assessment and Diagnosis’.2 CAD, coronary artery disease; CT, computed tomography; ECG, electrocardiogram; MR, magnetic resonance. Reprinted with the permission of the publisher from Chest Pain of Recent Onset.1
On the other hand, 2012 American College of Cardiology and American Heart Association (ACCF-AHA) guidelines for the diagnosis and management of patients with stable ischaemic heart disease (Figure 2) and 2013 European Society of Cardiology (ESC) guidelines on the management of stable CAD (Figure 3), rely on pre-test likelihood and offer a multiplicity of functional imaging tests as the first line diagnostic tool. The ACCF-AHA Guidelines support Class Ib recommendation for ETT, stress echocardiography (SE), and myocardial perfusion radionuclide imaging (MPI) and IIa for magnetic resonance imaging (MRI). Computed tomography (CT) angiography is reserved for patients with low-to-intermediate pretest probability of CAD who are incapable of at least moderate physical activity or have disabling comorbidity (Class IIa recommendation), and for patients with an intermediate pretest probability of CAD who can undertake at least moderate physical activity or reveal no disabling comorbidity (Class IIb recommendation). The ESC Guideline designates a Class Ib recommendation for all functional modalities, including MRI and positron emission tomography (PET). European Society of Cardiology also includes a Class IIa recommendation for CTA in patients in the lower range of intermediate pre-test probability when adequate diagnostic image quality can be expected, as an alternative to stress imaging, or after an inconclusive stress test, or for patients who have contraindications to stress testing in order to avoid otherwise necessary ICA. However, neither ACCF-AHA nor ESC documents had the benefit of the extensive CTA literature published since 2012–2013, which weighed into formulation of the NICE guidelines 2016 update vis-à-vis their departure from the conventional practices reflected in the 2012 American and 2013 European guidelines. It is not certain whether or not the next ACCF-AHA and ESC guidelines will come to similar conclusions as 2016 NICE update. However, it is important to examine the implications for the practicing cardiologists if the NICE guidelines were to be implemented universally.
2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischaemic heart disease.4 CCTA, coronary computed tomography angiography; CMR, cardiac magnetic resonance; ECG, electrocardiogram; Echo, echocardiography; IHD, ischaemic heart disease; MI, myocardial infarction; MPI, myocardial perfusion imaging; Pharm, pharmacological; UA, unstable angina; UA/NSTEMI, unstable angina/non-ST-elevation myocardial infarction. Reprinted with the permission of Elsevier from Fihn et al.4
European Society of Cardiology 2013 non-invasive testing in patients with suspected stable coronary artery disease and an intermediate pre-test probability.5 CAD, coronary artery disease; CTA, computed tomography angiography; CMR, cardiac magnetic resonance; ECG, electrocardiogram; ICA, invasive coronary angiography; LVEF, left ventricular ejection fraction; PET, positron emission tomography; PTP, pre-test probability; SCAD, stable coronary artery disease; SPECT, single-photon emission computed tomography. Reprinted with permission of Oxford Academic from Montalescot et al.5