1. Evaluation of CT Coronary Angiography (CTCA) and Cardiac Magnetic Resonance (CMR) in patients presenting with Acute Chest Pain (ACP) at A&E
Background
Acute Chest Pain (ACP) accounts for more than 700,000 visits to A&E departments in the UK per year in England and Wales.
Diagnoses of acute coronary syndrome are however comparatively rare and in between 50% and 85% of ACP presentations are diagnosed as being of non-cardiac related.
Patients without known Coronary Artery Disease (CAD) presenting with acute chest pain, of presumed cardiac origin, and no signs of acute myocardial ischaemia (as assessed by 12-lead ECG and troponin) and discharged to be subsequently referred for further assessment to either: i) Pathway 1: the patient’s GP; or ii) Pathway 2: the Rapid Access Chest Pain Clinic where CTCA and/or CMR will be available as expedited non-invasive imaging modalities.
Study aim: The TOHETI study aims to evaluate the efficiency, clinical care and patient experience associated with the use of CT Coronary Angiography (CTCA) and/or Cardiac Magnetic Resonance (CMR), in the assessment of patients with ACP referred from A&E to: i) either the patient’s GP; or ii) the Rapid Access Chest Pain Clinic (RACPC).
Study Design
The study will be an independent single Trust ED site (at St Thomas’ Hospital) prospective, non-randomised, non-blinded, cohort real world study.
The expected follow-up time is 12 months. In the event of patient death or failure to comply with study requirements, he/she will be excluded from the study. 40% and 50% of participants enrolled in the RACPC (Pathway 2) and GP group (Pathway 1), respectively, were assumed to be lost to follow-up. This assumption was considered in the sample size calculations.
For the purposes of the economic evaluation (consistent with secondary outcomes) quality of life and symptoms will be measured using the EQ-5D-5L questionnaire at baseline and then monthly after the ED admission. All relevant costs from an NHS and Personal Services perspective will be considered using a bottom-up costing strategy (consistent with GSTT finance data).
Assessment by clinician – myocardial ischaemia ECG? and/or Abnormal 1st troponin?
Patient presents at A&E (St Thomas’ Hospital) with symptoms of acute chest pain (ACP).
Not eligible for the study
Yes
Willing to participate in the study?
Patient discharged from A&E? No
Referred to GP
Referred to RACPC
Sign informed consent form and assess patient eligibility
Referral to GP appointment
Month 12
No Follow-up or Follow-up appointments and/or investigations
Pathway 1
Month 0 OR
CT Angiography (15-50% PTP) or CMR (50-85% PTP)
Referral to RACPC appointment
Pathway 2
Years 5
Follow-up
Long-term modelling based on the prevalence and severity of CAD
Questionnaires to be filled in by participants / interviews
Monthly follow-up
At A&E/UCC
Referral to GP (Pathway 1) or RACPC (Pathway 2)
Long-term
What will happen?
Final follow-up as part of the study
Month 12
Every Month 1
Study synopsis
Sample size
481 patients (219 in Pathway 2 - RACPC group - and 262 in Pathway 1 - GP group).
Primary objective
6-month total costs associated with the management of patients in both pathways
Secondary objectives
i) Patient satisfaction associated with both pathways;
ii) Clinical outcomes (e.g. MACE and readmission rates);
iii) Time and completeness of diagnosis;
iv) Cost analysis and cost-effectiveness analysis of the utilisation of CTCA in the context of RACPC.
“TOHETI explores how imaging technology can be better utilised to improve patient experience and outcome, and the acute chest pathway is a great example of this. By directly referring patients presenting to A&E with low risk acute chest pain for further cardiac evaluation with cardiac CT and/or MRI imaging in a follow-up clinic, we aim to streamline the outpatient referral process and improve clinical care and efficiency. Patients will also be provided with greater reassurance, and a clear plan for further clinical management, improving their experience at a worrying time for them and their families.”
Dr Waqar Aziz, Clinical research Fellow
ACP TOHETI study
CONTACT US: Clinical Research Fellow - Dr Waqar Aziz