Dr Monal Wadhera discusses how the diagnosis of coronary heart disease in the UK is changing.
Coronary heart disease (CHD) is a common sight in medical practices across the UK. Symptoms vary so broadly and can present differently in men and women. I may see a patient one day experiencing chest pain, while the next day I see someone experiencing jaw pain or shortness of breath.
As GPs, we have to make a call on onward referral. Historically when we’ve done this, our patients have been subject to stress tests or invasive testing such as angiograms. The latter, in particular, brings risks of complication and in many cases may be unnecessary if the patient is found to have only moderate or minor levels of disease. As well as this, in the current climate sending patients into hospital for potentially invasive procedures that could expose them or healthcare workers to Covid-19 is an additional risk we must balance.
But the way we diagnose CHD in the UK is changing.
Adopting a non-invasive approach to diagnosis
National Institute of Health and Care Excellence (NICE) guidelines push a CT-first approach to diagnosis for patients with stable chest pain.
In these instances, opting for a coronary CT angiography (CTA) as the first line of investigation has been shown to improve the accuracy of diagnoses in patients with mild to moderate cases of CHD. In fact, the five-year results of the SCOT-HEART study found that a CTA-guided diagnosis resulted in more patients being treated with medication and preventative therapies. And 12 months later, fewer people were undergoing invasive testing such as angiography or revascularization procedures.
What’s more, the study found that patients who had undergone a CTA had better outcomes overall due to the more accurate diagnoses and treatment plans they’d received.
Adopting a digital approach to diagnosis is a gamechanger for our patients, helping them to avoid unnecessary procedures while also freeing up waiting lists for more serious cases that may need stenting or even bypass surgery.
Many hospitals in the UK are now adopting NICE guidelines and it’s something that patients may undergo if experiencing stable chest pain. More recently, recommendations have been updated to include the HeartFlow FFRct Analysis, an Artificial Intelligence-led technology. This innovation provides a unique value, known as fractional flow reserve, derived from computed tomography (FFRct), which estimates pressure differences across a coronary narrowing.
Improving access to technology
Thanks to the NHS’ Innovation and Technology Payment (ITP) programme, which seeks to accelerate the uptake of digital technologies within the health service by removing financial barriers to their adoption, FFRct is becoming increasingly available in trusts across NHS England.
The technology takes the data from a coronary CT scan and uses a combination of deep learning and highly trained analysts to create a 3D digital model of a patient’s heart. Its algorithms solve millions of equations to simulate blood flow in a patient’s arteries and help clinicians assess the functional impact of any blockages.
Anatomical information from a CT scan and functional information from the FFRct can help determine the severity of CHD without the need for further invasive testing. This accelerates the time it takes for a patient to receive their diagnosis and treatment plan.
The 3D model also proves a great tool for showing patients exactly what’s going on in their coronary arteries and can help improve understanding of any further interventions they may need.
Studies show that using this technology can improve patient outcome compared to CT alone. For example, the ADVANCE registry study found that using FFRct changed a doctor’s recommended treatment plan in two thirds of patients. This meant that in some cases, patients could avoid operations and be treated medically.
Putting patient experience first
Being able to offer our patients insights into the latest diagnostic options available to them can help them understand the process much better and reassure them that they may not need to undergo an invasive procedure. Having knowledge of a CT-first approach also means I can answer questions from patients on subsequent visits to the practice who may feel uncertain and have additional questions about the referral decision to send them on for further investigation for CHD.
It’s fantastic to see our health service adopting new technologies that improve patient outcomes and help to prioritise resources for those who need them most. As we progress through the Covid-19 pandemic, knowing patients that I refer on for cardiac investigations may be able to reduce their time in hospitals by having just one CT-scan, will help to reduce risks and could offer much-needed peace of mind.