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Author: Huang Xingtao Xing Chun Hou Jingbo*
2021 strong1_strong editor in Europe The Late Breaking Science in Imaging special session announced the three latest scientific researches at the annual meeting of the Society of Diseases and Diseases (ESC). This journal specially invites The Second Affiliated Hospital of Harbin Medical University Hou Jingbo's team to comment on the topic, and learn in-depth with you .
Research background
The current ESC chronic coronary syndrome (CCS) guidelines recommend that patients with stable angina pectoris should be assessed for the pretest probability (PTP) of coronary heart disease (CAD) based on symptoms, gender, and age, PTP≤5 % No further examination is required, and further clinical evaluation can be done when PTP is between 5~15%, such as exercise load test and so on. However, whether these additional assessments are of practical significance has not yet been fully determined. Therefore, such patients and those with PTP>15% are recommended for cardiac imaging to further diagnose obstructive CAD. The main purpose of this study is to evaluate the clinical practice of CCS patients when choosing imaging strategies and their compliance with the 2019 ESC CCS guidelines.
Research method
A total of 24 countries (21 European countries, 3 non-European countries) and 5156 suspected CCS patients were enrolled in 73 centers. The selected population is mainly based on the clinically common suspected CCS conditions pointed out in the 2019 ESC CCS guidelines.The endpoints of the study were: (1) the compliance with the ESC CCS guidelines selected for the first imaging examination; (2) the compliance with the ESC CCS guidelines throughout the diagnosis process.
research results
research center and population distribution results are shown in Figure 1. Most research centers and research populations come from Southern Europe, followed by Eastern Europe.
Figure 1. Distribution of research centers and research population
The average age of the research population is 64±11 years old, and the clinical characteristics of the patients are shown in Figure 2.
Figure 2. Clinical characteristics of the study population
Among the examinations performed by all patients (Figure 3), 32% of the patients underwent exercise stress ECG examinations. The first imaging examinations were coronary CTA (CCTA) and SPECT The proportion of people is similar, about 24%. In 15% of patients, the first imaging examination was stress echocardiography. Other imaging examinations (such as CMR and PET) are rarely used as the first imaging examination. 29% of patients underwent invasive coronary angiography (ICA) examination, and more than half of them chose coronary angiography for the first imaging examination. Only a few patients underwent FFR examination.
Figure 3. Cardiovascular examination options for the general population
Finally, 24% of patients were diagnosed with obstructive CAD, 19% of patients had induced ischemia, and only 13% of patients received revascularization therapy. In addition, 38% of patients have non-obstructive CAD, which means that more than 60% of patients have a clear diagnosis of CAD, which may be the reason for the change in interventions. Further subgroup analysis showed that whether it was the proportion of CAD diagnoses, the proportion of ischemia, the proportion of revascularization, or the proportion of changes in early intervention, the PTP group and the left ventricular ejection fraction (LVEF) group gradually increased ( Figure 4).
Figure 4. The proportion of diagnosed CAD and early intervention measures in the overall population and subgroups of the population
further analyze the compliance with the guidelines in the diagnosis and treatment process,It was found that 56.5% of the patients followed the recommendations of the guidelines for the first imaging examination, 40.6% of the patients did not follow the recommendations of the guidelines, and 2.9% were unclear. 49.5% of the patients followed the guidelines and recommendations throughout the diagnosis process, 47.4% did not follow the guidelines, and 3.1% were unclear. The results showed that a large number of patients did not follow the guidelines in the diagnosis process (Figure 5).
Figure 5. The overall population compliance with the guidelines
Further analysis of the selection of the first imaging examination (Figure 6), close to 20% of patients only underwent exercise stress ECG examination, 18% chose ICA for the first imaging examination For examination, nearly 40% of patients chose stress imaging examination for the first imaging examination, and more than 20% chose CCTA. Subgroup analysis showed that only the first selection ratio of exercise stress ECG examination decreased in each subgroup as the probability of suffering from CAD increased. Patients with PTP ≤ 5% used exercise stress ECG as the first examination to comply with the guidelines, while the other groups of patients chose exercise stress ECG as the first examination method were the choices that did not follow the guidelines. However, a large proportion of patients in this group still choose ICA, stress imaging examinations and CCTA as their first imaging examinations, which is inconsistent with the guidelines. The selection ratio of ICA gradually increased in the PTP group and the previous CAD group, but only in the subgroup with LVEF<50%>
Figure 6. Compliance with guidelines in each subgroup population
Univariate and multivariate analysis showed that more professional cardiovascular center treatments, typical angina pectoris, CAD family history, previous revascularization, LVEF<50%>
Figure 7. Analysis of factors leading to the patient's choice of first influential examinations not complying with the 2019 ESC CCS guidelines
univariate and multivariate analysis showed that,Family history of CAD, dyslipidemia , previous revascularization, exercise stress ECG examination, and ICA examination were the main factors that led to the entire diagnosis process not complying with the 2019 ESC CCS guidelines. On the other hand, performing stress imaging examinations and CCTA are the main factors for the entire diagnosis process to comply with the 2019 ESC CCS guidelines (Figure 8).
Figure 8. Analysis of factors leading to patients' compliance or non-compliance with the 2019 ESC CCS guidelines during the entire diagnosis process
The impact of compliance with the guidelines on the entire diagnosis and treatment is summarized in Figure 9. It can be seen from the figure that the proportion of patients who did not follow the guidelines was referred for ICA, which was nearly three times that of patients who followed the guidelines. On the other hand, patients who followed the guidelines found a higher proportion of patients with severe obstructive CAD (60% vs 40%).
Figure 9. The proportion of patients who follow the guidelines for referral to ICA is lower, and the diagnosis accuracy is higher. The selection of academic examinations usually does not follow the recommendations of the 2019 ESC CCS guidelines. Patients treated in cardiovascular centers and those with higher expected risk are more likely to not follow the guidelines. Exercise stress ECG examination and the use of ICA examination instead of non-invasive imaging examination are the main reasons why most patients do not follow the guidelines. It is worth noting that patients who follow the guidelines recommended process have a lower probability of being referred for ICA examination, and the positive diagnosis rate of ICA examination is higher.
Expert comment
At the 2019 ESC Conference, the "Guidelines for the Diagnosis, Treatment and Management of Chronic Coronary Syndrome" (the 2019 ESC CCS Guidelines) was released. The new guidelines introduce the new concept of " coronary heart disease clinical possibility ",On the basis of "pre-test probability (PTP)", combined with the evaluation of clinical factors, the clinical possibility of CAD is inferred, and the diagnostic examination strategy is selected according to the clinical possibility. The guidelines point out that non-invasive imaging examination is the first choice for coronary heart disease screening (Class I recommendation), and for patients with a high clinical likelihood of coronary heart disease, invasive examinations such as coronary angiography are the first choice (Class I Recommended) . The new guidelines put forward higher requirements for clinicians' risk assessment capabilities. However, there is still a lack of data on whether the guidelines can be followed during the actual diagnosis and treatment of CCS, and whether compliance with the guidelines can bring related benefits. The EURECA research results released at the ESC conference in 2021 answered this question. The
EURECA study is a multi-center large sample observational study, which mainly explores whether patients suspected of having CCS follow the latest guidelines and recommendations (the 2019 ESC CCS guidelines) during the diagnosis process. Through a detailed analysis of the diagnosis process of 5156 suspected CCS patients, it was found that most (56.5%) of the patients’ first choice of imaging examination did not follow the guideline recommendations, and almost half (49.5%) of the entire diagnosis process did not Follow the guidelines recommendations. This is a result worthy of discussion and reflection. What causes 's poor compliance with the guidelines ? Certain answers are also given in this research. After multivariate analysis, it was found that 's professional cardiovascular center treatments and patients with higher expected risks are more likely to not follow the guidelines . This conclusion is more in line with the reality. In professional cardiovascular centers, because of the conditions for invasive imaging examinations, doctors may prefer to allow patients to undergo ICA examinations directly instead of passing other non-invasive imaging examinations according to the guidelines. Screening. For people with higher risk, in order to avoid possible risks during the examination, clinicians are more likely to directly perform ICA examinations to confirm the diagnosis and enter the next step of treatment.
However, medicine is an evidence-based science, and guidelines are usually formulated based on a large amount of evidence-based medicine, which is relatively scientific and reasonable. Therefore, the benefits of following the recommendations of the guidelines are obvious.In the results of the EURECA study, it was found that patients who followed the guidelines recommended process had fewer unnecessary ICA examinations, which reduced the waste of medical resources, and the positive rate of ICA examinations was higher. This result demonstrates the benefits of following the guidelines.
Therefore, the significance of the EURECA study is to reveal the current clinical compliance with the 2019 ESC CCS guidelines, factors that may affect clinical compliance with the guidelines, and the benefits of following the guidelines in the diagnosis of CCS, reminding the clinic Doctors change some " experience talk", and try their best to follow the recommendations of the guidelines in the process of CCS diagnosis and treatment.
Expert profile
Professor Hou Jingbo
Doctor of Medicine, postdoctoral, chief physician, second-level professor, doctoral supervisor, deputy director of the Department of Cardiology, the Second Affiliated Hospital of Harbin Medical University, and myocardial ischemia of the Ministry of Education Deputy Director of Key Laboratory.
Main research field: Research on the mechanism of coronary heart disease atherosclerosis. Main academic part-time jobs: Longjiang Scholar Distinguished Professor, Longjiang Famous Doctor, won the 14th Harbin Youth Science and Technology Award.
concurrently serving as a member of the Standing Committee of the Cardiovascular Branch of the Chinese Medical Association, the deputy head of the intracavitary imaging and physiology group of the Cardiovascular Branch of the Chinese Medical Association, a member of the Cardiovascular Branch of the Chinese Medical Association and a member of the Thrombology Group;
Heilongjiang Medical Association Vice Chairman of the Vascular Professional Committee; Vice Chairman of the Cardiovascular Medicine Professional Committee of the Heilongjiang Medical Association; Vice President of the Heilongjiang Cardiology Association; FACC, FSCAI, etc. concurrently serves as the communications editor of the 9th Editorial Committee of Chinese Journal of Cardiovascular Diseases; is a member of the editorial board of "JACC Journal Chinese Edition"; "EHJCI" is a Chinese edition member.
Responsible for 4 National Natural Science Foundation of China, won the Heilongjiang Provincial Government, Huaxia Medical, Chinese Medical Science and Technology First Prize, National Science and Technology Progress Second Prize, and Ministry of Education Science and Technology Progress Second Prize each.
published 62 first and communication SCI articles, IF>20 points 2 articles, the highest IF 23.4.
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(Source: "International Circulation" editorial department)
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