Comparison of NICE and ESC proposed strategies on new onset chest pain and the contemporary clinical utility of pretest probability risk score.

AIMS: Patients with de novo chest pain are usually investigated non-invasively. The new UK-National Institute for Health and Care Excellence (NICE) guidelines recommend CT coronary angiography (CTCA) for all patients, while European Society of Cardiology (ESC) recommends functional tests. We sought to compare the clinical utility and perform a cost analysis of these recommendations in two UK centres with different primary investigative strategies. METHODSRESULTS: We compared two groups of patients, group A (n=667) and group B (n=654), with new onset chest pain in two neighbouring National Health Service hospitals, each primarily following either ESC (group A) or NICE (group B) guidance. We assessed the clinical utility of each strategy, including progression to invasive coronary angiography (ICA) and revascularisation. We present a retrospective cost analysis in the context of UK tariff for stress echo (£176), CTCA (£220) and ICA (£1001). Finally, we sought to identify predictors of revascularisation in the whole population.Baseline characteristics in both groups were similar. The progression to ICA was comparable (9.9% vs 12.0%, p=0.377), with similar requirement for revascularisation (4.0% vs 5.0%.; p=0.532). The average cost of investigations per investigated patient was lower in group A (£279.66 vs £325.77), saving £46.11 per patient. The ESC recommended risk score (RS) was found to be the only predictor of revascularisation (OR 1.05, 95% CI 1.04 to 1.06; p<0.001). CONCLUSION: Both NICE and ESC-proposed strategies led to similar rates of ICA and need for revascularisation in discrete, but similar groups of patients. The SE-first approach had a lower overall cost by £46.11 per patient, and the ESC RS was the only variable correlated to revascularisation.

Usefulness of Cardiac Magnetic Resonance Imaging to Measure Left Ventricular Wall Thickness for Determining Risk Scores for Sudden Cardiac Death in Patients With Hypertrophic Cardiomyopathy.

Echocardiography-derived measurements of maximum left ventricular (LV) wall thickness are important for both the diagnosis and risk stratification of hypertrophic cardiomyopathy (HC). Cardiac magnetic resonance (CMR) imaging is increasingly being used in the assessment of HC; however, little is known about the relation between wall thickness measurements made by the 2 modalities. We sought to compare measurements made with echocardiography and CMR and to assess the impact of any differences on risk stratification using the current European Society of Cardiology guidelines. Maximum LV wall thickness measurements were recorded on 50 consecutive patients with HC. Sixty-nine percent of LV wall thickness measurements were recorded with echocardiography, compared with 69% from CMR (p <0.001). There was poor agreement on the location of maximum LV wall thickness; weighted-Cohen's κ 0.14 (p = 0.036) and maximum LV wall thicknesses were systematically higher with echocardiography than with CMR (mean 19.1 ± 0.4 mm vs 16.5 ± 0.3 mm, p <0.01, respectively); Bland-Altman bias 2.6 mm (95% confidence interval -9.8 to 4.6). Interobserver variability was lower for CMR (R2 0.67 echocardiography, R2 0.93 CMR). The mean difference in 5-year sudden cardiac death (SCD) risk between echocardiography and CMR was 0.49 ± 0.45% (p = 0.37). When classifying patients (low, intermediate, or high risk), 6 patients were reclassified when CMR was used instead of echocardiography to assess maximum LV wall thickness. These findings suggest that CMR measurements of maximum LV wall thickness can be cautiously used in the current European Society of Cardiology risk score calculations, although further long-term studies are needed to confirm this.