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Does angiography help in risk stratification?

Does angiography help in risk stratification?. Derek Harrington Maidstone and Tunbridge Wells NHS Trust. Medium sized DGH 300,000 population Two Consultant Cardiologists Derek Harrington Clive Lawson. Kent and Sussex Hospital, Tunbridge Wells. Derek and Clive.

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Does angiography help in risk stratification?

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  1. Does angiography help in risk stratification? Derek Harrington Maidstone and Tunbridge Wells NHS Trust

  2. Medium sized DGH 300,000 population Two Consultant Cardiologists Derek Harrington Clive Lawson Kent and Sussex Hospital, Tunbridge Wells

  3. Derek and Clive

  4. Does angiography help in risk stratification? Should coronary angiography be performed on ACS patients in DGHs without on site PCI?

  5. TACTICS TIMI 18 19.4% 15.9% 20 16 12 O.R 0.78 95% CI (0.62, 0.97) p=0.025 % Patients with 10 endpoint 8 4 CONS INV 0 0 1 2 3 4 5 6 Time (months) Cannon et al NEJM 2001

  6. Invasive ACS - the DGH view • Identify all high / intermediate risk patients • Appropriate medical therapy • Arrange angiography / revascularisation within 48 hours

  7. Invasive ACS - the DGH view • 48 hours not achieved in many tertiary centres • Miller, Lipscomb, Curzen 2003 • Waiting time 13 days vs 5 days • “This inequity of access is determined by postcode rather than clinical priority”

  8. Invasive ACS – the DGH view • Large numbers of patients, 10 per week • “U&Es, Trop I” • Long transfer time (3 – 4 weeks, Mean 22 days) • Potentially one ward full of patients waiting transfer for angiography / revascularisation • Majority asymptomatic

  9. Alternative approaches • Further risk stratify, exercise testing etc, with outpatient investigation for some

  10. Local Coronary Angiography

  11. TW ACS • The majority of patients undergo angiography within one week • Decision to discharge etc, based upon anatomy + other risk factors

  12. DGH angiography, arguments against • Too dangerous in DGH • Large numbers of patients will require a second procedure • Angiography will delay definitive treatment

  13. Too dangerous in the DGH • Common sense • TW n=215 complications=0 • Published series suggest that DGH angiography is safe • Large programme of DGH catheter laboratories • Generally more senior operators

  14. DGH angiography, arguments against • Too dangerous in DGH • Large numbers of patients will require a second procedure • Angiography will delay definitive treatment

  15. Need for a second procedure Approx 60% patients will not require further angiography

  16. TACTICS – medical treatment

  17. DGH angiography, arguments against • Too dangerous in DGH • Large numbers of patients will require a second procedure • Angiography will delay definitive treatment

  18. Angiography delays definitive treatment • LMS • Proximal LAD • 3VD – Early surgical referral Rapid Transfer

  19. Angiography will delay definitive treatment • Home for early “elective PCI” • Earlier identification of very high risk and surgical patients • More tertiary referral beds for “interventional transfers”

  20. Conclusions • Safe in DGH • Some patients will require a second procedure • Early Angiography may enable rapid revascularisation • Marked reduction in bed occupancy, happier patients • A prelude to DGH angioplasty

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