“Prepare the umbrella before it rains.”
– Malay Proverb
Is it possible that the decisions made in 2016 by a group of healthcare analysts and clinicians have made England’s hospitals better prepared to provide quality cardiovascular care during the COVID-19 pandemic? In a word, yes.
In 2016, clinical guidance from the United Kingdom’s National Institute for Health and Care Excellence (NICE) indicated that hospitals should forego functional testing and instead begin utilizing coronary CTA for stable chest pain patients across the spectrum of pre-test likelihood of coronary artery disease (CAD). And in 2017, NICE recommended use of the HeartFlow FFRCT Analysis to aid in determining which patients whose CTA showed CAD of uncertain functional significance should be considered for invasive assessment.
These clinical recommendations were incredibly bold when announced 3 to 4 years ago. As such, they were met with both excitement and some incredulity as national leaders recognized that CT capacity would have to be expanded by 700% to meet the clinical demand this clinical pathway would create.
Fast forward to 2020, and leading NHS England facilities that have adopted this CT+FFRCT pathway are now reporting significant clinical advantages that are even more valuable in the time of COVID.
For example, the Freeman Hospital within the Newcastle NHS system in northeast England, has one of the busiest interventional programs in the UK. As they adopted the NICE guidance, this system found a:
- 63% increase in coronary CTA as a front-line test
- 44% reduction in front-line functional testing
- 33% reduction in diagnostic angiography (ICA)
- 73% increase in the proportion of ICAs leading to revascularization, as opposed to findings of no obstructive disease.
Newcastle’s experience is not unique. NHS facilities in Bath in England’s southwest report similar findings, including:
- 7x increase in coronary CTA with no increase in functional testing
- Interventional procedure volume overtaking diagnostic procedure volume in the cath lab for the first time
These data are even more powerful in light of recent guidance from leading cardiovascular societies to “avoid elective procedures when possible” (ACC & SCAI) and that “coronary CTA should be preferred… during COVID-19 pandemic” as it is “accurate, fast and minimizes the exposure of patients.” (ESC)
What the team at NICE recognized in 2016, and continues to emphasize in 2020, is that CT+FFRCT offers a fast, safe, and non-invasive path to diagnostic clarity for stable symptomatic patients in whom CAD is suspected. In 2016, many viewed the reductions in interactions between patient and provider, and reduced duplicative testing and invasive diagnostic procedures simply as health economic and patient experience benefits. Today, however, we view these as critical safety factors that allow providers and health care facilities to manage cardiovascular patients effectively in the COVID-19 era.
Changes to improve patient care will always create some disruption, but they become a necessity when a clinician may only have one chance to make the right call. Kudos to those at NICE and NHSE for their bold decisions that are bearing fruit in a time when providers and patients need it most.