Change in preventive cardiovascular therapy with the implementation of the new chest pain pathway in patients with suspected stable CAD a single centre experience NHS-England pilot project

Abstract Background The 2-weeks wait pathway of the Rapid Access Chest Pain Clinic (RACPC) had been under regular scrutiny. Cardiac CT angiography (CCTA) as part of the triaging tool was introduced in 2010. Based on coronary plaque burden patients can be risk stratified, and treatment initiated. An AI based risk score using the perivascular fat attenuation index (FAI) was developed and validated as a gage of coronary inflammation and predictor of cardiovascular mortality in patients with CAD. Hypothesis:With the emerging evidence to show clinical and monetary value of the AI-based CariHeart Risk score the need for reforming the current chest pain pathway (CP) was proposed. The impact of a CariHeart Risk score based new chest pain pathway (NP) was tested in 5 NHS Hospitals. In this study we report our initial experience of the NP implementation in a single Hospital. Methods We analysed the difference in initiation/intensification (INI) of cardiovascular preventive therapy (CVPT) including Statin, Aspirin, Ezetimibe, Colchicine, between the CP, based on nurse assessment followed by CCTA and consultant cardiologist recommendation - vs the extended CCTA analysis involving FAI and CariHeart risk assessment-based management – NP. 135 consecutive patients referred to the RACPC are part of this analysis. 2 patients had no contrast CCTA images and were excluded. Results The degree of atherosclerosis CAD was defined as No-or Mild, 50%, Moderate, 50-69%, Severe 70% stenosis, respectively. The INI-CVPT was recommended for 40 (30%) patients in the CP and 112 (84%) in the NP groups (p0.01) the rest was a continuation of therapy. No de-escalation of medication was recommended in either of the groups. The number of recommending INI-CVPT was 31(23%) and 86 (65%) for Statin, 11 (8%) and 75 (56%) for Ezetimibe, 10 (8%) and 36 (27%) for Antiplatelet and 6 (5%) and 20 (15%) for Colchicine in the CP and NP groups, respectively. There was significantly higher rate of INI-CVPT in the no or mild CAD group with the NP vs CP (99 (87%) vs 28 (25%). The INI-CVPT in the NP group was associated with the higher proportion of the aggregate intermediate /high FAI (≥50 percentile for LAD/RCA or ≥50 for LCX) and CariHeart risk scores (≥1% eight-year CV mortality) respectively. The INI-CVPT for the moderate and severe CAD groups were similar. In the intermediate/high percentile FAI group there was significantly higher treatment INI rate, 78% vs 13% and 87% vs 35% in the NP vs CP, respectively. The same patter was seen when the intermediate/high score CariHeart risk groups. Conclusion The implementation of the NP incorporating the AI-based CariHeart risk score has led to higher rate of INI-CVPT compared to CP. Based on FAI and CariHeart scores 70% of patients with intermediate/high risk score in the CP group and 16% in the NP group were under-treated. Further research into understanding the value of INI-CVPT on perivascular inflammation and cardiovascular death is essential.