NICE Guidance for Stable Chest Pain Patients (CG95 & MTG32) to Appropriately Diagnose Patients with Suspected Coronary Artery Disease

The team’s cardiologist, with extensive experience in CT imaging, recognised the value of cardiac CT imaging as well as its limitations. Cardiac CT imaging can provide exceptional anatomic data without an invasive procedure. The modality is limited, however, in that it does not provide functional blood flow information. HeartFlow FFRCT, an emerging technology recommended by NICE in February 2017 (MTG32), takes the data from a standard cardiac CT and calculates blood flow measurements throughout the coronary tree. The team realised that these tests together would enable physicians to make accurate and appropriate clinical decisions while avoiding the need for invasive cardiac catheterisation.

Emerging HeartFlow clinical data was researched further and this eventually led to LHCH’s adoption of the technology with the objective of improving the diagnosis and care for LHCH patients with suspected coronary artery disease by 1) increasing access to cardiac CT and 2) enabling access to HeartFlow FFRCT when necessary.

There are 2.3 million people in the UK living with coronary heart disease (British Heart Foundation 2017). Thousands of patients present each year to LHCH with chest pain seeking help and appropriate care. While multiple non-invasive diagnostic tests are available, these tests have limited accuracy. As a result, thousands of patients receive multiple tests with indeterminate results. There are often long wait times and treatment decisions are delayed as physicians seek to determine the source of the patient’s pain. Patients are left in limbo, often kept from work and day to day life and anxious about their medical condition. Even after layers of testing, the right decision remains unclear.

In the end, many of these patients are referred on for an invasive angiography, a procedure which requires the insertion of a catheter into the coronary arteries, which carries with it high costs, patient discomfort, and some risk of complications.

It is well established in the clinical literature that the majority of patients undergoing invasive angiography after diagnostic testing are found not to have obstructive disease. These angiographies result in significant costs and risks that could potentially be avoided. These challenges have resulted in the recent updates to NICE guidelines on chest pain (CG95) and NICE recommendations on HeartFlow FFRCT (MTG32).

Liverpool Heart and Chest (LHCH) is the largest angioplasty (PCI) centre in the UK. With a catchment of over 2.8m individuals, we perform more than 7,000 non-invasive diagnostic tests per year. Modalities include stress echo, SPECT, cardiac MR, and CT. LHCH is committed to advancing cardiovascular diagnostics and care and as such was one of the first centres in the UK to begin using HeartFlow’s FFRCT technology. 

The team took a scientific approach in evaluating cardiac CT and HeartFlow FFRCT. After reviewing data from several clinical trials, it was concluded that the incorporation of these technologies could improve care for LHCH patients. Implementing these improvements at LHCH was no small task. It required two significant steps which both involved revising clinical practices to reflect clinical guidance from NICE.

The first step was to increase access to cardiovascular CT. In November 2016, NICE published updated guidelines for patients with recent onset chest pain (CG95). In these guidelines, NICE recommends CT as a first line test for patients with typical or atypical angina chest pain. The team’s cardiac consultant led his practice in adopting these guidelines and driving CT utilisation. Such a significant shift required support across clinical teams and hospital management. In just one year, with the support of these teams the consultant led efforts to increase cardiac CT volumes by more than 30% from 2,300 to 3,050. LHCH has emerged as a leading CT institution and patient access to cardiac CT continues to grow.

The second step involved adherence to NICE medical technologies guidance (MTG32) which recommends HeartFlow be used following a CT for patients where results are indeterminate. While recommended by NICE, HeartFlow is a new technology with limited availability in the UK. After researching the clinical evidence, the reviewing consutant provided information to the heart team at LHCH. As there is not yet reimbursement for HeartFlow, it was necessary to demonstrate not only the clinical but also economic benefits of HeartFlow adoption. With support from hospital management LHCH became one of three hospitals in the UK to provide access to HeartFlow through the ADVANCE Registry. The reviewing cardiology consultant continues to engage with hospital management and commissioners as they are now updating patient pathways so HeartFlow use can expand with funding in the future.

As we look at the objectives of AHPs into Action, these improvements deliver on Impact, Commitment, and Priorities.

Impact: “Deliver evidence based/informed practice to address unexplained variances in service quality and efficiency.” – LHCH heart team adopted both NICE clinical guidelines CG95 and NICE medical technologies guidance MTG32. This has resulted in improved, consistent, and efficient care of patients with suspected coronary artery disease.

Commitment: “Commitment to the individual.” – the LHCH cardiology team has demonstrated their commitment to providing each of their patients with a speedy, accurate, and non-invasive diagnosis of their chest pain. This would not have occurred without the training and education of other physicians and staff at LHCH so that the team could adhere to NICE guidance.

Priorities: “AHPs can utilise information and technology.” – LHCH made the bold decision (and presented a business case) to adopt a new NICE recommended technology, HeartFlow FFRCT. As a new technology, it required expertise and support from the LHCH IT team. Expanded use of CT along with HeartFlow’s technology are revolutionising the care of patients with suspected coronary artery disease. Leadership, based on close examination of data about HeartFlow FFRCT, followed by a structure adoption and implementation strategy have meant that LHCH has provided this technology to more patients than any other hospital in the UK. 

LHCH has learned a great deal while implementing both the NICE chest pain guidelines (CG95) and the NICE recommendations on HeartFlow (MTG32). The path has had its share of challenges. Some of these have been highlighted in the Adoption Guide on HeartFlow FFRCT. 

One clear learning is that the successful adoption of this new technology requires broad support and clinical governance. In order to enable the electronic transfer of CT data required for a HeartFlow analysis, LHCH had to receive internal IT approval. IT was actively involved in setting up the technology to ensure that it functioned correctly and securely.

In addition to IT, revising patient pathways to reflect NICE recommendations required broad support across LHCH clinical teams and hospital management. While all members of LHCH team are seeking the best care for patients, each department has their own view on how that care should be delivered. Numerous meetings were held with fellow physicians and hospital administration in order to facilitate communication and education about HeartFlow FFRCT. However, the effort was worthwhile as it drove significant improvements in care, benefiting a large number of patients.