Downstream testing after CT coronary angiography: time for a rethink?

OBJECTIVE: We surveyed UK practice and compliance with the National Institute for Health and Care Excellence (NICE) 'recent-onset chest pain' guidance (Clinical Guideline 95, 2016) as a service quality initiative. We aimed to evaluate the diagnostic utility and efficacy of CT coronary angiography (CTCA), NICE-guided investigation compliance, invasive coronary angiography (ICA) use and revascularisation. METHODS: A prospective analysis was conducted in nine UK centres between January 2018 and March 2020. The reporter decided whether the CTCA was diagnostic. Coronary artery disease was recorded with the Coronary Artery Disease-Reporting and Data System (CAD-RADS). Local electronic records and picture archiving/communication systems were used to collect data regarding functional testing, ICA and revascularisation. Duplication of coronary angiography without revascularisation was taken as a surrogate for ICA overuse. RESULTS: 5293 patients (mean age, 57±12 years; body mass index, 29±6 kg/m²; 50% men) underwent CTCA, with a 96% diagnostic scan rate. 618 (12%) underwent ICA, of which 48% (298/618) did not receive revascularisation. 3886 (73%) had CAD-RADS 0-2, with 1% (35/3886) undergoing ICA, of which 94% (33/35) received ICA as a second-line test. 547 (10%) had CAD-RADS 3, with 23% (125/547) undergoing ICA, of which 88% (110/125) chose ICA as a second-line test, with 26% (33/125) leading to revascularisation. For 552 (10%) CAD-RADS 4 and 91 (2%) CAD-RADS 5 patients, ICA revascularisation rates were 64% (221/345) and 74% (46/62), respectively. CONCLUSIONS: While CTCA for recent-onset chest pain assessment has been shown to be a robust test, which negates the need for further investigation in three-quarters of patients, subsequent ICA overuse remains with almost half of these procedures not leading to revascularisation.

The effects and costs of home-based rehabilitation for heart failure with reduced ejection fraction: The REACH-HF multicentre randomized controlled trial.

BACKGROUND: Cardiac rehabilitation improves health-related quality of life (HRQoL) and reduces hospitalizations in patients with heart failure, but international uptake of cardiac rehabilitation for heart failure remains low. DESIGN AND METHODS: The aim of this multicentre randomized trial was to compare the REACH-HF (Rehabilitation EnAblement in CHronicHeart Failure) intervention, a facilitated self-care and home-based cardiac rehabilitation programme to usual care for adults with heart failure with reduced ejection fraction (HFrEF). The study primary hypothesis was that the addition of the REACH-HF intervention to usual care would improve disease-specific HRQoL (Minnesota Living with Heart Failure questionnaire (MLHFQ)) at 12 months compared with usual care alone. RESULTS: The study recruited 216 participants, predominantly men (78%), with an average age of 70 years and mean left ventricular ejection fraction of 34%. Overall, 185 (86%) participants provided data for the primary outcome. At 12 months, there was a significant and clinically meaningful between-group difference in the MLHFQ score of -5.7 points (95% confidence interval -10.6 to -0.7) in favour of the REACH-HF intervention group ( p = 0.025). With the exception of patient self-care ( p < 0.001) there was no significant difference in other secondary outcomes, including clinical events ( p > 0.05) at follow-up compared with usual care. The mean cost of the REACH-HF intervention was £418 per participant. CONCLUSIONS: The novel REACH-HF home-based facilitated intervention for HFrEF was clinically superior in disease-specific HRQoL at 12 months and offers an affordable alternative to traditional centre-based programmes to address current low cardiac rehabilitation uptake rates for heart failure.

A randomised controlled trial of a facilitated home-based rehabilitation intervention in patients with heart failure with preserved ejection fraction and their caregivers: the REACH-HFpEF Pilot Study.

INTRODUCTION: Home-based cardiac rehabilitation may overcome suboptimal rates of participation. The overarching aim of this study was to assess the feasibility and acceptability of the novel Rehabilitation EnAblement in CHronic Hear Failure (REACH-HF) rehabilitation intervention for patients with heart failure with preserved ejection fraction (HFpEF) and their caregivers. METHODS AND RESULTS: Patients were randomised 1:1 to REACH-HF intervention plus usual care (intervention group) or usual care alone (control group). REACH-HF is a home-based comprehensive self-management rehabilitation programme that comprises patient and carer manuals with supplementary tools, delivered by trained healthcare facilitators over a 12 week period. Patient outcomes were collected by blinded assessors at baseline, 3 months and 6 months postrandomisation and included health-related quality of life (primary) and psychological well-being, exercise capacity, physical activity and HF-related hospitalisation (secondary). Outcomes were also collected in caregivers.We enrolled 50 symptomatic patients with HF from Tayside, Scotland with a left ventricular ejection fraction ≥45% (mean age 73.9 years, 54% female, 100% white British) and 21 caregivers. Study retention (90%) and intervention uptake (92%) were excellent. At 6 months, data from 45 patients showed a potential direction of effect in favour of the intervention group, including the primary outcome of Minnesota Living with Heart Failure Questionnaire total score (between-group mean difference -11.5, 95% CI -22.8 to 0.3). A total of 11 (4 intervention, 7 control) patients experienced a hospital admission over the 6 months of follow-up with 4 (control patients) of these admissions being HF-related. Improvements were seen in a number intervention caregivers' mental health and burden compared with control. CONCLUSIONS: Our findings support the feasibility and rationale for delivering the REACH-HF facilitated home-based rehabilitation intervention for patients with HFpEF and their caregivers and progression to a full multicentre randomised clinical trial to test its clinical effectiveness and cost-effectiveness. TRIAL REGISTRATION NUMBER: ISRCTN78539530.

Usefulness of 64-detector row computed tomography for evaluation of intracoronary stents in symptomatic patients with suspected in-stent restenosis.

To determine whether 64-slice multidetector computed tomographic coronary angiography (MDCTA) can accurately assess the coronary artery lumen in symptomatic patients with previous coronary artery stents and potential in-stent restenosis (ISR). The primary aim was to determine the accuracy of binary ISR exclusion using MDCTA compared with invasive catheter angiography (ICA). Secondary aims were comparisons of stent dimensions measured using MDCTA and variables that affect accuracy. Forty patients with previous stent placement underwent both ICA and 64-slice MDCTA after elective presentation with chest pain, and ICA quantitative coronary angiographic data were used as the reference standard. Thirty-six men and 4 women (age 64 +/- 10 years; range 44 to 83) with 103 stents (2.8 +/- 1.6 stents/patient) were comparatively evaluated (stent exclusion rate 9.6%). There were 45 bare-metal and 58 drug-eluting stents (20 +/- 18 months after implantation) with an average diameter of 3.23 +/- 0.7 mm. Overall accuracy for the detection of significant ISR showed sensitivity, specificity, and positive and negative predictive values of 85%, 86%, 61%, and 96% for proximal stents > or =3 mm, which improved to 100%, 94%, 81%, and 100%; if the visible luminal diameter on MDCTA was <1.5 mm, accuracy decreased to 40%, 84%, 29%, and 90%, respectively. In conclusion, 64-slice MDCTA assessment of symptomatic patients with suspected clinically significant ISR is a realistic alternative to ICA if reference stent diameter is > or =2.5 mm and visible lumen cross-sectional diameter is > or =1.5 mm, for which a negative MDCTA result virtually excludes the presence of significant ISR.