RESUMEN
AIM: To quantify the real-world clinical and cost impact of computed tomography (CT) coronary angiography (CTCA)-derived fractional flow reserve (FFRCT) in the National Health Service (NHS). MATERIALS AND METHODS: Consecutive clinical CTCA examinations from September to December 2018 with ≥1 stenosis of ≥25% underwent FFRCT analysis. The Heart Team reviewed clinical data and CTCA findings, blinded to FFRCT values, and documented hypothetical consensus management. FFRCT results were then unblinded and hypothetical consensus management re-recorded. Diagnostic waiting times for management pathways were estimated. A per-patient cost analysis for diagnostic certainty regarding coronary artery disease (CAD) management was performed using 2014-2020 NHS tariffs for pre- and post-FFRCT pathways. RESULTS: Two hundred and fifty-one CTCAs were performed during the study period. Fifty-seven percent (145/251) had no CAD or stenosis <25%. One study was non-diagnostic. Of the remaining 42% (105/251), two were ineligible for FFRCT and there was a 5% (5/103) failure rate. FFRCT led to a change in hypothetical management in 65% (64/98; p<0.001) patients with a functional imaging test cancelled in 17% (17/98) and a diagnostic angiogram cancelled in 47% (46/98). FFRCT-guided management had a reduced mean time to definitive investigation compared with CTCA alone (28 ± 4 versus 44 ± 4 days; p=0.004). Using the proposed 2020/21 tariff, CTCA + FFRCT for stenosis ≥50% resulted in a diagnostic pathway £44.97 more expensive per patient than usual care without FFRCT. CONCLUSIONS: In the real-world NHS setting, FFRCT-guided management has the potential to rationalise patient management, accelerate diagnostic pathways, and depending on the stenosis severity modelled, may be cost-effective.
Asunto(s)
Angiografía por Tomografía Computarizada/economía , Angiografía por Tomografía Computarizada/métodos , Angiografía Coronaria/economía , Angiografía Coronaria/métodos , Estenosis Coronaria/diagnóstico por imagen , Costos y Análisis de Costo/métodos , Reserva del Flujo Fraccional Miocárdico/fisiología , Estenosis Coronaria/economía , Estenosis Coronaria/fisiopatología , Costos y Análisis de Costo/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Medicina Estatal , Reino UnidoRESUMEN
A 57-year-old man presented at our institution with central chest pain. Serial ECGs showed dynamic T-wave changes, suggesting the possibility of unstable angina. Urgent coronary angiography revealed an unexpected finding of a radio-opaque lesion seen in the xiphisternal region during screening. Oesophogastroduodenoscopy confirmed this to be a 10p coin. The coin passed through the gastrointestinal tract without complications and the patient's symptoms and ECG changes resolved. This unusual case is a reminder that many diseases may electrocardiographically imitate an acute coronary syndrome.