Coronary artery disease (CAD) is an important differential diagnosis of chest pain. The 2010 NICE Clinic Guideline 95 (CG95) – ‘Chest Pain of Recent Onset’, recommends investigating the complaint of chest pain by stratifying patients’ CAD risk according to the modified Diamond Forrester criteria. Patients possessing high (61–90%) CAD risk should be offered invasive coronary angiogram as first line investigation. However, a significant proportion of high risk patients will instead receive functional testing such as dobutamine stress echocardiography (DSE), which is recommended for moderate risk patients. A negative DSE in high risk patients will still considered as negative for significant CAD, but the prognosis of these patients, who are usually discharged from cardiology follow up, is unclear. This study aims to assess the prognosis of high CAD risk patients following a negative DSE in the first two year after the implementation of the 2010 NICE guideline.Methods
This is a retrospective study at a district general hospital. We identified high CAD risk patients who were referred for DSE from the rapid access chest pain (RACP) clinic. We clarified the reasons why patients were not referred for coronary angiography. Patients with negative DSE were followed up via the hospital’s electronic record system, which contains all clinical information including hospital admissions and discharge letters, outpatient attendances and clinical letters, diagnostic tests and results, and date of death.Results
504 patients were referred for DSE from the RACP clinic between September 2010 and August 2012. 164 patients possessed high risk for CAD. 52 were referred based on patient choice, 54 based on clinical assessment, and 7 possessed contraindications to invasive angiography. 117 high risk patients had a negative DSE; these patients were followed up for at least 12 months (median 21 months, maximum 30 months). 4 (3.4%) high CAD risk patients required further hospital review due to persistent cardiac symptoms and additional cardiac investigations following a negative DSE. Within this group, 1 case (0.8%) had significant CAD identified on angiography requiring percutaneous coronary intervention. The remaining 113 (96.6%) were free from significant clinical complaints requiring hospital attendance during follow up.Conclusion
In the first 2 years following the implementation of NICE CG95, we identified a significant number of patients with high CAD risk, who were offered DSE. The reasons for selecting DSE over conventional angiography were due to the clinician’s judgement of appropriateness and patient choice in equal parts. The medium term outcome of those who have had a negative DSE is favourable, with only a few (<5%) requiring additional cardiac investigation and 1 case (<1%) of significant coronary disease. Thus, a negative DSE is a reliable objective indicator of good prognosis in patients with high risk of CAD in a chest pain clinic.