Real-world clinical and cost analysis of CT coronary angiography and CT coronary angiography-derived fractional flow reserve (FFRCT)-guided care in the National Health Service

Graby, John; Metters, Rhys; Kandan, Sri Raveen; McKenzie, Daniel B; Lowe, Rodney; Carson, Kevin; Hudson, Benjamin; Rodrigues, Jonathan

doi:10.1016/j.crad.2021.06.009

Cited by 11 publications

(5 citation statements)

References 19 publications

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“…a cost per patient encounter to reach treatment, regardless of what investigations are done), and if CTCA-first reduces layered testing then it may be cost-effective. 23 The proposed future vision to increase outpatient imaging service delivery within community diagnostic hubs (as proposed by the Richards report 24 ) may also enhance scanning capacity on a national level, as will the current drive to increase the number of CTCA reporters via amendments to both radiology and cardiology training curriculums. Additionally, a CTCA-first strategy would have improved adherence to NICE-CG95 6 whilst also reducing the time-to-diagnosis vs functional testing, which may miss non-obstructive CAD.…”

Section: Discussionmentioning

confidence: 99%

CT coronary angiography first prior to rapid access chest pain clinic review: a retrospective feasibility study

Graby

Murphy

Metters

et al. 2023

BJR

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Objectives: Since rapid access chest pain clinics (RACPC) were established to streamline stable chest pain assessment, CT coronary angiography (CTCA) has become the recommended investigation for patients without known coronary artery disease (CAD), with well-defined indications. This single-centre retrospective study assessed the feasibility of GP-led CTCA prior to RACPC. Methods: RACPC pathway patients without pre-existing CAD electronic records were reviewed (September-October 2019). Feasibility assessments included appropriateness for RACPC, referral clinical data versus RACPC assessment for CTCA indication and safety, and a comparison of actual versus hypothetical pathways, timelines and hospital encounters. Results: 106/172 patients screened met inclusion criteria (mean age 61 ± 14, 51% female). 102 (96%) referrals were ‘appropriate’. No safety concerns were identified to preclude a GP-led CTCA strategy. The hypothetical pathway increased CTCA requests versus RACPC (84 vs 71), whilst improving adherence to guidelines and off-loading other services. 22% (23/106) had no CAD, representing cases where one hospital encounter may be sufficient. The hypothetical pathway would have reduced referral-to-diagnosis by at least a median of 27 days (IQR 14–33). Conclusion: A hypothetical GP-led CTCA pathway would have been feasible and safe in a real-world RACPC patient cohort without pre-existing CAD. This novel strategy would have increased referrals for CTCA, whilst streamlining patient pathways and improved NICE guidance adherence. Advances in knowledge: GP-led CTCA is a feasible and safe pathway for patients without pre-existing CAD referred to RACPC, reducing hospital encounters required and may accelerate time to diagnosis. This approach may have implications and opportunities for other healthcare pathways.

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Section: Discussionmentioning

confidence: 99%

CT coronary angiography first prior to rapid access chest pain clinic review: a retrospective feasibility study

Graby

Murphy

Metters

et al. 2023

BJR

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“…ML-based CT-FFR now enables such a workflow without the time or cost restraints applicable to earlier approaches [ 21 , 22 , 23 ] with the computation of CT-FFR on-site. However, our results demonstrate a false positive rate of 70% for CT-FFR in cCTA studies without morphological signs of obstructive CAD (no stenosis ≥50%).…”

Section: Discussionmentioning

confidence: 99%

“…Furthermore, CT-FFR has been proposed to mitigate the apparent challenges in reading cCTA, when serving as a guide to morphological coronary analysis, improving interpretation speed and reader confidence, particularly for less experienced readers [ 20 ]. However, commercially available off-site solutions to CT-FFR are impractical for this purpose, as they require several hours for processing and are also costly [ 21 , 22 , 23 ]. Newer approaches to CT-FFR, namely those based on machine learning (ML), are much less computationally demanding and can be calculated on site in just a few seconds [ 24 ].…”

Section: Introductionmentioning

confidence: 99%

Combined Coronary CT-Angiography and TAVI Planning: Utility of CT-FFR in Patients with Morphologically Ruled-Out Obstructive Coronary Artery Disease

Gohmann

Seitz

Pawelka

et al. 2022

JCM

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Background: Coronary artery disease (CAD) is a frequent comorbidity in patients undergoing transcatheter aortic valve implantation (TAVI). If significant CAD can be excluded on coronary CT-angiography (cCTA), invasive coronary angiography (ICA) may be avoided. However, a high plaque burden may make the exclusion of CAD challenging, particularly for less experienced readers. The objective was to analyze the ability of machine learning (ML)-based CT-derived fractional flow reserve (CT-FFR) to correctly categorize cCTA studies without obstructive CAD acquired during pre-TAVI evaluation and to correlate recategorization to image quality and coronary artery calcium score (CAC). Methods: In total, 116 patients without significant stenosis (≥50% diameter) on cCTA as part of pre-TAVI CT were included. Patients were examined with an electrocardiogram-gated CT scan of the heart and high-pitch scan of the torso. Patients were re-evaluated with ML-based CT-FFR (threshold = 0.80). The standard of reference was ICA. Image quality was assessed quantitatively and qualitatively. Results: ML-based CT-FFR was successfully performed in 94.0% (109/116) of patients, including 436 vessels. With CT-FFR, 76/109 patients and 126/436 vessels were falsely categorized as having significant CAD. With CT-FFR 2/2 patients but no vessels initially falsely classified by cCTA were correctly recategorized as having significant CAD. Reclassification occurred predominantly in distal segments. Virtually no correlation was found between image quality or CAC. Conclusions: Unselectively applied, CT-FFR may vastly increase the number of false positive ratings of CAD compared to morphological scoring. Recategorization was virtually independently from image quality or CAC and occurred predominantly in distal segments. It is unclear whether or not the reduced CT-FFR represent true pressure ratios and potentially signifies pathophysiology in patients with severe aortic stenosis.

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“…FFR-CT can be used as an alternative functional assessment tool concurrently with other non-invasive functional imaging tests. The use of FFR-CT can assist in avoiding unnecessary invasive coronary angiography 40,41 , however its true cost-effectiveness is still up for debate 42 .…”

Section: Notesmentioning

confidence: 99%

Role of non-invasive coronary imaging in stable angina

Adnan,

Panjiyar,

Mehmood

et al. 2024

gcsp

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Chest pain represents a symptom of significant clinical concern due to the potential for lethal etiologies. Accordingly, it is critical to ascertain the presence of stable angina through various diagnostic tests to inform subsequent therapeutic strategies. Stable angina, while potentially progressing to more severe conditions if left untreated, suffers from a paucity of research regarding its management compared to other more fatal causes of chest pain. Recent advancements in radiological imaging necessitate a re-evaluation of the array and functionality of diagnostic tests, with particular emphasis on prioritizing non-invasive methods such as electrocardiography and echocardiography. This study undertakes a comprehensive review of the literature pertaining to various diagnostic tests for stable angina. We conclude that the management of a patient presenting with chest pain encompasses a continuum of care, beginning with a detailed patient history to estimate pre-test probability and culminating in computed tomography coronary angiography. This continuum is highly individualized, taking into account patient-specific variables, disease burden, and test indications. In an era of rapid research advancement, our findings delineate the optimal sequence of initial diagnostic tests, emphasizing the role of current non- invasive imaging modalities as outlined in standard clinical guidelines.

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Real-world clinical and cost analysis of CT coronary angiography and CT coronary angiography-derived fractional flow reserve (FFRCT)-guided care in the National Health Service

Cited by 11 publications

References 19 publications

CT coronary angiography first prior to rapid access chest pain clinic review: a retrospective feasibility study

CT coronary angiography first prior to rapid access chest pain clinic review: a retrospective feasibility study

Combined Coronary CT-Angiography and TAVI Planning: Utility of CT-FFR in Patients with Morphologically Ruled-Out Obstructive Coronary Artery Disease

Role of non-invasive coronary imaging in stable angina

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