Introduction NICE guidance (NG95) recommends the use of non-invasive anatomical and/or functional testing prior to invasive coronary angiography (iCA) to evaluate and diagnose recent-onset chest pain of suspected cardiac origin. We have previously demonstrated significantly higher rates of revascularisation (OR 3.19, C.I 1.29 to 7.46, p=0.0163) in patients with stable chest pain referred for iCA with prior non-invasive cardiac testing. Aim Our service and quality improvement project employed a PDSA (Plan, Do, Study, Act) model (figure 1) to identify the proportion of patients referred appropriately for iCA for potential revascularisation. We aimed to introduce an intervention strategy to improve catheter laboratory efficiency and utilisation through appropriate patient referral pathways. This strategy was developed through an electronic prompt on the referral system, signposting referrers to NG95 guidance, in addition to the delivery of local departmental education at clinical governance meetings. Methods We conducted retrospective, single-centre, pre- and post-intervention cohort studies of stable chest pain patients referred for iCA and potential revascularisation over two 6 month periods (Pre-intervention cycle – April to September 2022, Post-intervention cycle – January to June 2024). Data was collected from booking and clinic records, and analysed for age, demographics, prior non-invasive cardiac testing and revascularisation rates. Primary outcome data was analysed using Chi-square testing and defined as: Appropriateness of iCA referral pathways for stable chest pain patients Revascularisation rates (defined as either PCI or cardiac surgical referral) Secondary outcomes included symptom resolution in the revascularisation group. Results A total of 139 patients were referred for iCA and potential revascularisation: 95 patients in the pre-intervention and 44 patients in the post-intervention groups respectively (mean age 69 vs. 68 years). The proportion of inappropriate referrals for iCA decreased from 34% (32/95) pre-intervention to 20% (9/44) in the post-intervention group (OR 1.98, CI 0.85–4.61, p=0.1116), representing a relative risk reduction of 39% in inappropriate referrals (figure 2). In the post-intervention group, 71% (25/35) of patients with prior non-invasive imaging underwent revascularisation compared to only 56% (5/9) in those who did not (OR 2.0, C.I 0.44 to 9.01, p=0.3668). Of 20 patients followed post revascularisation, 85% (17/20) had symptom resolution by 8 months. 3 patients had persistent symptoms of angina at 4 and 5 month follow up respectively, with 1 patient requiring emergency admission at 10 months with ongoing symptoms. Conclusions Our intervention resulted in a significant reduction of stable chest pain patients referred inappropriately for iCA, thereby improving catheter laboratory utilisation and efficiency. Individuals that have prior non-invasive cardiac testing were significantly more likely to undergo revascularisation in both cohort groups. A large proportion of patients undergoing revascularisation benefitted from symptom resolution by 8 months, highlighting the importance of revascularisation as a treatment strategy for chronic coronary syndromes.
Tomlinson et al. (Wed,) studied this question.