Cardiac Investigation Trends Among Primary Care Physicians: A Paradigm Shift.

OBJECTIVE: While numerous recent guidelines support coronary computed tomography angiography (CTA) as a first-line test for stable chest pain, it remains underutilized by primary care physicians (PCPs). We aimed to evaluate cardiac investigation ordering practices following education sessions, as well as the total number of downstream tests and time to diagnosis for patients presenting with stable chest pain. METHODS: A retrospective chart review was completed for eligible patients assessed at the Women's College Hospital Family Practice Health Centre between 2017 and 2019 following the education sessions. The outcome measures were first-choice cardiac investigation, additional downstream testing, time from presentation to first investigation, and time to final diagnosis. RESULTS: 419 patients were included in the final analysis (74.70% female; mean age 61 ± 11 years). Coronary CTA requests by PCPs increased between 2017 and 2019 (18 vs 72 tests; P < .0001). When coronary CTA was the first-line test, patients were less likely to receive additional downstream testing when compared to those receiving other first-line investigations (P < .0001). Coronary CTA was associated with longer time to diagnosis than stress echocardiography (47 ± 45 vs 27 ± 36 days; P = .0068) due to limited availability of coronary CTA appointment times. There was no significant difference in time to final diagnosis among the cardiac imaging modalities observed in the cohort (P = .0623). CONCLUSION: Utilization of coronary CTA as the first-line test for stable chest pain increased following our education sessions targeting PCPs. Coronary CTA was associated with less downstream testing compared to other non-invasive cardiac investigations.

Cardiac Link: a retrospective cohort study evaluating a clinical pathway for expedited cardiology referral.

BACKGROUND: Outpatients presenting with chest pain often face long wait times for cardiology consultation and subsequent investigation for obstructive coronary artery disease (CAD), during which adverse cardiovascular events may occur. Our objective was to describe the design of Cardiac Link, a coronary computed tomography angiogram (CCTA)-guided rapid-access program, and evaluate its effect on cardiology consultation wait times in patients who present to primary care physicians with stable chest pain. METHODS: We conducted a retrospective cohort study at Women's College Hospital, Toronto, Ontario, Canada, between 2017 and 2020 involving eligible patients from the Family Practice Health Centre who underwent CCTA after presenting with stable chest pain or equivalent symptoms. Referring primary care physicians decided on a patient-by-patient basis to opt into the Cardiac Link program when requesting CCTA. Our primary outcome was measure of time from CCTA to cardiology consultation, and our secondary outcomes were measures of time to diagnosis from primary care consultation and CCTA booking time. RESULTS: Our analysis included 148 patients (Cardiac Link n = 98, non-Cardiac Link n = 50). Mean age of the patients was 58.4 (SD 11.2) years and 72% (107/148) were women. We found that the Cardiac Link group had a shorter time from CCTA to cardiology consultation (median 7 [interquartile range {IQR} 6-20] d v. median 100 [IQR 40-138] d; p = 0.01), shorter time to diagnosis (median 33 [IQR 22-55] d v. median 86 [IQR 40-112] d; p < 0.001) and shorter CCTA booking time (median 18 [IQR 11-31] d v. median 65 [IQR 24-92] d; p < 0.001) compared with the non-Cardiac Link group. INTERPRETATION: We determined that the Cardiac Link program reduced cardiology consultation wait times for symptomatic patients who were suspected of having CAD. Our study shows the viability of CCTA-guided rapid-access programs to expedite specialist consultation and reduce unnecessary referral for patients presenting to primary care physicians with stable chest pain.