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Underuse of non-invasive functional imaging in patients at intermediate risk of coronary artery disease. A decision support system in the clinical practice. The ARTICA database.

Session Digital health analysis

Speaker Alison Pottle

Event : ESC Congress 2018

  • Topic : e-cardiology / digital health, public health, health economics, research methodology
  • Sub-topic : Digital Health, Other
  • Session type : Moderated Posters

Authors : M Mazzanti (London,GB), E Shirka (Tirana,AL), F Pugliese (London,GB), H Gjergo (Tirana,AL), A Goda (Tirana,AL), A Pottle (Harefield,GB), E Hasimi (Tirana,AL), SE Deane (London,GB), N Dent (London,GB), N Mackay (London,GB), SE Underwood (London,GB)

Authors:
M. Mazzanti1 , E. Shirka2 , F. Pugliese3 , H. Gjergo2 , A. Goda2 , A. Pottle4 , E. Hasimi2 , S.E. Deane5 , N. Dent5 , N. Mackay5 , S.E. Underwood6 , 1Royal Brompton Hospital - London - United Kingdom , 2University Hospital Center Mother Theresa, Cardiology - Tirana - Albania , 3Barts Health NHS Trust, Cardiac Imaging - London - United Kingdom , 4Harefield Hospital, Nurse Consultant - Harefield - United Kingdom , 5Harefield Hospital, Nurse in Cardiology - London - United Kingdom , 6Imperial College London, RBH Nuclear Medicine - London - United Kingdom ,

Citation:
European Heart Journal ( 2018 ) 39 ( Supplement ), 41

Background: Non-invasive functional imaging (NIFI) can accurately rule out hemodynamically significant coronary artery disease (CAD) and can act as a gatekeeper for invasive revascularization.

Purpose: To analyze an integrated approach by a clinical decision support system (DSS) vs standard care (STD) in patients (pts) at intermediate pre-test likelihood of CAD referred for stable chest pain evaluation.

Methods: 498 pts (303 males and 195 females, age 56±6 years) were referred for stable chest pain evaluation over a 16 month period in three different hospitals. A computerized browsing automated DSS and a human cardiologist STD were applied during the same day visit. Pre-test likelihood of CAD was based on Clinical score + coronary artery calcium scoring (CACS). Significant CAD (>50% coronary stenosis) criteria were applied in all pts by computerized tomography coronary angiography (CTCA).

Results: Pre-test likelihood of CAD is shown in the Table. 281 (56.4%) pts were classified as “No further test (NFT)”, 182 (36.5%) “Ex test (ET)/Functional Imaging (FI)” and only 34 (6.8%) “CTCA” and 1 (0.3%) “(ICA)” by DSS. Of note, DSS “ET/FI” + “NFT” and STD “ET/FI” + “NFT” + “CTA” subgroups identified respectively 391 (78.5%) and 372 (74.6%) pts free of significant CAD or inducible myocardial ischemia (p=0.3). The diagnostic accuracy of DSS “ET/FI” + “NFT” (without “CTA” data) class resulted 92.5%.

Conclusions: The data suggests that direct visualization of the coronary arteries did not add any value for the diagnosis of CAD. However, it should be noted that “No further test +/− functional imaging” class is a powerful negative predictive value for significant CAD. Therefore DSS could represent a valid solution for prescribing the correct test for risk stratification at point-of-care.

Table 1
(n/%)Clinical Score + CAC (n/%)
Low-to-intermediate (212 / 21.5)Intermediate (277 / 28.2)Intermediate-to-high (9 / 0.9)
CDSS (n/%)
  NFT (281 / 56.4)121 / 57.0160 / 57.70 / 0
  ET/FI (182 / 36.5)68 / 32.0109 / 39.35 / 55.5
  CTA (34 / 6.8)23 / 11.08 / 3.03 / 33.3
  ICA (1 / 0.3)0 / 00 / 01 / 11.2
STD (n/%)
  NFT (6 / 1.3)6 / 2.80 / 00 / 0
  ET/FI (69 / 13.8)34 / 16.135 / 12.60 / 0
  CTA (404 / 81.1)172 / 81.1227 / 81.95 / 55.5
  ICA (19 / 3.8)0 / 015 / 5.54 / 45.5

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