Role of non-invasive imaging in the management of coronary artery disease: an assessment of likely change over the next 10 years. A report from the British Cardiovascular Society Working Group

Abstract

Coronary angiography has been the gold standard for determining the severity, extent and prognosis of coronary atheromatous disease for the past 15-20 years. However, established non-invasive testing (such as myocardial perfusion scintigraphy and stress echocardiography) and newer imaging modalities (multi-detector x ray computed tomography and cardiovascular magnetic resonance) now need to be considered increasingly as a challenge to coronary angiography in contemporary practice. An important consideration is the degree to which appropriate use of such techniques impacts on the need for coronary angiography over the next 10-15 years. This review aims to determine the role of the various investigation techniques in the management of coronary artery disease and their resource implications, and should help determine future service provision, accepting that we are in a period of significant technological change.

Systematic review of the clinical effectiveness and cost-effectiveness of 64-slice or higher computed tomography angiography as an alternative to invasive coronary angiography in the investigation of coronary artery disease

“…CT is very quick, and faster than CA, and so probably much less expensive, as well as being less invasive, although the radiation dose is higher than the average 4-8-mSv exposure quoted by the TEC report 10 or the below 5% exposure quoted by a British Cardiovascular Society Working Group report 12 for invasive angiography. The radiation dose is also higher with 64-slice than 16-slice (about 11 versus 6 mSv) 8 but there are ways of reducing the dose such as ECG-dependent dose modulation and reduced tube voltage.…”

“…The QUADAS tool was adapted to make it more applicable to evaluating the methodological quality of studies reporting tests for diagnosing and assessing CAD (see Appendix 2 for an example of the modified checklist). Questions 1,3,4,5,6,7,10,11,12,13 and 14 of the original QUADAS tool were retained (questions 1-11 in the modified version). Three questions in the original QUADAS tool that related to the quality of reporting rather than methodological quality were omitted from the modified version (questions 2, 8 and 9).…”

“…Across the studies reporting this information for the patient group as a whole, the CT radiation dose ranged from 6-11 mSv 55 to [10][11][12][13][14]58 with all studies using ECGcontrolled dose modulation. In studies reporting CT radiation dose separately for men and women, women tended to receive a higher dose.…”

Prognostic Implication of Appropriateness Criteria for Pharmacologic Stress Echocardiography Performed in an Outpatient Clinic

“…2 The expansion of stress imaging is also expected in the United Kingdom, with a predicted 2-fold increase of pharmacological stress echocardiography and myocardial scintigraphy during the next decade. 3 Whether this rate of growth translates into clinical benefit to patients remains under debate. [3][4][5][6][7] Indeed, the increased utilization of diagnostic imaging has not been paralleled by a reduction in disease burden as the rate of hospitalization for myocardial infarction has remained nearly constant over time.…”

“…3 Whether this rate of growth translates into clinical benefit to patients remains under debate. [3][4][5][6][7] Indeed, the increased utilization of diagnostic imaging has not been paralleled by a reduction in disease burden as the rate of hospitalization for myocardial infarction has remained nearly constant over time. 1 The growth of stress imaging raises concerns because of its economical impact [5][6][7] in the face of reduced available resources, the exposure of patients to potential risks of the study, 8 and the excessive delay in evaluation and management due to waiting for test performance and interpretation.…”