Recommendations for research
- 1 Cost-effectiveness of multislice CT coronary angiography for ruling out obstructive coronary artery disease in people with troponin-negative acute coronary syndromes
- 2 Refining the use of telephone advice in people with chest pain
- 3 Establishing a national registry for people who are undergoing initial assessment for stable angina
- 4 Information about presenting and explaining tests
In 2010, the guideline committee made the following recommendations for research. The committee's full set of research recommendations is detailed in the full guideline.
1 Cost-effectiveness of multislice CT coronary angiography for ruling out obstructive coronary artery disease in people with troponin-negative acute coronary syndromes
Is multislice CT coronary angiography a cost-effective first-line test for ruling out obstructive coronary artery disease (CAD) in people with suspected troponin-negative acute coronary syndromes?
Current European Society of Cardiology guidelines state that in troponin-negative ACS with no ST‑segment change on the ECG, 'a stress test is recommended… in patients with significant ischaemia during the stress test, coronary angiography and subsequent revascularisation should be considered'. Yet stress testing has relatively low sensitivity and specificity for diagnosing CAD in this group of people. Therefore a significant proportion of at-risk people are missed while others with normal coronary arteries are subjected to an unnecessary invasive coronary angiogram. Multislice CT coronary angiography is highly sensitive and provides a potentially useful means for early rule-out of CAD in troponin-negative acute coronary disease. We need to know whether it is cost effective compared with exercise ECG as a first test in the diagnostic work-up of this group.
In what circumstances should telephone advice be given to people calling with chest pain? Is the appropriateness influenced by age, sex or symptoms?
The telephone is a common method of first contact with healthcare services, and produces a near uniform emergency response to chest pain symptoms. Such a response has considerable economic, social and human costs. Research should be conducted to clarify if an emergency response in all circumstances is appropriate, or if there are identifiable factors such as age, sex or associated symptoms that would allow a modified response and a more appropriate use of resources.
3 Establishing a national registry for people who are undergoing initial assessment for stable angina
Can a national registry of people presenting with suspected angina be established to allow cohort analysis of treatments, investigations and outcomes in this group? Such a registry would provide a vital resource for a range of important research projects, including:
development and validation of a new score for assessing the pre-test probability of disease, addressing outstanding uncertainties in the estimation of the pre-test probability of CAD based on simple measures made at initial assessment (history, examination, routine bloods, resting 12‑lead ECG)
assessment of the extent to which new circulating biomarkers add additional information to measures made at initial assessment
provision of a framework for trial recruitment without significant work-up bias allowing evaluation of the diagnostic and prognostic test performance of CT‑based, MR, echocardiography and radionuclide technologies.
A national prospective registry of consecutive people with suspected stable angina before initial diagnostic testing does not currently exist in the UK or in any other country. Establishing such a registry would offer the following methodological strengths: statistical size, representative patients without work-up bias, contemporary data. This would overcome key problems in much of the existing evidence base.
Accurate assessment of pre-test likelihood of coronary disease is needed to inform the cost-effective choice of investigative technologies such as CT coronary calcium scoring for people with chest pain that may be caused by myocardial ischaemia. The data on which pre-test likelihood is based date from 1979 in a US population and may not be applicable to contemporary UK populations. There remain continuing uncertainties about the initial assessment of people with suspected stable angina. For example, the possible contributions of simple clinical measures such as body mass index, routine blood markers (for example, haemoglobin) or novel circulating biomarkers to estimates of the pre-test likelihood of CAD are not known and require further assessment in the whole population and in predefined subgroups including ethnic minorities.
All people presenting with chest pain will need to decide whether to accept the diagnostic and care pathways offered. How should information about the diagnostic pathway and the likely outcomes, risks and benefits, with and without treatment, be most effectively presented to particular groups of people, defined by age, ethnicity and sex?
Methods of communication (both the content and delivery) will be guided by current evidence-based best practice. Controlled trials should be conducted based on well-constructed randomised controlled clinical trials comparing the effects of different methods of communication on the understanding of the person with chest pain. Such studies might consider a number of delivery mechanisms, including advice and discussion with a clinician or a specialist nurse, as well as specific information leaflets or visual data.
Any trials should also investigate the feasibility of introducing a suggested guideline protocol to be used with all people presenting with chest pain when faced with options concerning their clinical pathway.
Only by clearly explaining and then discussing the proposed diagnostic and care pathways can the healthcare professional be reasonably certain that informed consent has been obtained and that a patient's moral, ethical and spiritual beliefs, expectations, and any misconceptions about their condition, have been taken into account. Consideration should be given to any communication problems the person may have.