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Non-invasive assessment prior to invasive coronary angiography in routine clinical practice in Switzerland - Is it according to the guidelines?

Rebecca Schiefer, Hans Rickli, Evelyne Neurauter, Marc Buser, Daniel Weilenmann & Micha T. Maeder

abstract

BACKGROUND
Non-invasive testing is recommended as a basis to decide about the indication for invasive coronary angiography (ICA) in patients with suspected stenotic coronary artery disease (CAD). However, a recent study based on insurance claims data reported that one third of patients undergoing ICA in Switzerland did not have non-invasive testing beforehand. We aimed to re-evaluate the practice of testing prior to ICA in Switzerland by manual review of patient histories.

METHODS
Retrospective analysis of all 816 consecutive patients (age 67±9 years, 70% males) undergoing elective ICA solely for the evaluation of stenotic CAD during the year 2015 in a single center in Eastern Switzerland. The proportion of patients undergoing a non-invasive test was assessed, and predictors of the lack of such a test were determined.

RESULTS
764/816 (94%) patients had a non-invasive test prior to ICA. The majority of patients (728/816; 89%) had an exercise stress test, one fifth (160/816; 20%) underwent a test other than an exercise stress test (6% scintigraphy, 4% stress echocardiography, 6% stress magnetic resonance imaging, 4% computed tomography coronary angiography), and 122/816 (15%) patients had two tests. The use of antianginal drugs other than beta-blockers [odds ratio 1.92 (95% confidence interval 1.01-3.66); p = 0.047] and a lower left ventricular ejection fraction [odds ratio 0.97 (95% confidence interval 0.94-0.99) per one % point increase; p = 0.005] were independent predictors of the lack of a non-invasive test. ICA revealed stenotic CAD in 72% of patients, and 54% of patients underwent revascularization. Patients with and without non-invasive tests did not differ with respect to ICA findings and management.

CONCLUSIONS
The present analysis suggests that patients are appropriately selected for ICA based on clinical judgement and non-invasive testing in Switzerland. There is no evidence for an overuse of ICA.
   
citation Schiefer R, Rickli H, Neurauter E, Buser M, Weilenmann D, Maeder M T. Non-invasive assessment prior to invasive coronary angiography in routine clinical practice in Switzerland - Is it according to the guidelines?. PLoS ONE 2019; 14:e0222137.
   
type journal paper/review (English)
date of publishing 06-09-2019
journal title PLoS ONE (14/9)
ISSN electronic 1932-6203
pages e0222137
PubMed 31491029
DOI 10.1371/journal.pone.0222137