A leading heart specialist based at Southampton’s teaching hospitals has said that a commonly used test for diagnosis and subsequent treatment of angina is often “flawed”.
Coronary angiography – x-rays taken via tubes which are put in the wrist or groin to inject dye into the coronary arteries to highlight narrowings – is currently considered to be the ‘gold standard’ method for diagnosing angina – a painful tightening of the chest caused by heart disease.
Also known as coronary artery disease, heart disease develops when a build-up of fatty substances blocks or interrupts the blood supply to the heart. It is the most common cause of angina and heart attacks and is responsible for 82,000 deaths in the UK every year.
Professor Nick Curzen, a consultant cardiologist at Southampton General Hospital, said angiograms would be more accurate if combined with a pressure wire to assess the severity of blockages at the diagnostic stage.
Used in conjunction with angiography, the additional test, known as fractional flow reserve (FFR), would allow doctors to choose the most appropriate management plan for their patients, which could be medical management, the insertion of a stent (angioplasty) or coronary artery bypass graft surgery.
The tiny wire, which is passed into individual major arteries to measure pressure within the vessel itself, gives a precise reading of whether or not blood flow is significantly restricted through the coronary artery, which is vital in deciding if a patient requires a stent or surgery.
In a study presented at the European Association of Percutaneous Cardiovascular Interventions (EuroPCR) congress, Prof Curzen found more than a quarter (26%) of stable heart disease patients would have had the wrong treatment plan based just on angiogram alone.
As part of the project coordinated from Southampton, cardiologists at ten sites across the UK performed diagnostic angiograms on 200 patients with stable chest pain and drew up their treatment plans based on the initial assessment before leaving the room to allow a second cardiologist to carry out the pressure test.
Results were then shared with each patient’s original doctor – those who performed the initial angiograms – to give them an opportunity to see if the additional information would alter their decisions.
In 26% of cases, the management plan changed after the cardiologist had seen the FFR information and further analysis showed the pressure wire measurement changed cardiologists' opinion on whether or not individual coronary arteries had "significant" narrowings in almost a third of vessels (32%).
“Although this was a proof-of-concept study, the results indicate management of patients with stable angina by angiogram alone is probably flawed and treatment would be much more tailored to the individual through routine use of a FFR pressure test at the diagnostic stage,” said Prof Curzen.
“Not only did we see a quarter of treatment plans change, decisions on the significance of a patient’s disease changed in a third of patients following the inclusion of FFR information, which suggests there is real need for the specialty to rethink the most effective universal approach.”
Prof Curzen said a large randomised trial comparing angiography and FFR-guided assessment and management of patients with stable angina was now needed to provide comprehensive data on cost as well as clinical outcomes.
He added: "We are now working with collaborators to design such a trial and attract funding for it and, if this large scale study is positive, it could lead to a major change in practice in this area of medicine.”
Posted on Monday 10 June 2013