Journal Information
Share
Share
Download PDF
More article options
Visits
...
Guidelines
Open Access
Available online 16 October 2021
Consensus document on chronic coronary syndrome assessment and risk stratification in Portugal: A position paper statement from the [Portuguese Society of Cardiology’s] Working Groups on Nuclear Cardiology, Magnetic Resonance and Cardiac Computed Tomography, Echocardiography, and Exercise Physiology and Cardiac Rehabilitation
Documento de Consenso sobre Estratificação de Risco Cardiovascular e estudo da doença coronária em Portugal: a posição dos Grupos de Estudo de Cardiologia Nuclear, Ressonância Magnética e Tomografia Computorizada Cardíaca, de Ecocardiografia e de Fisiopatologia do Esforço e Reabilitação Cardíaca
Visits
...
Nuno Bettencourta,
Corresponding author
bettencourt.n@gmail.com

Corresponding author.
, Lígia Mendesb, José Paulo Fontesc, Pedro Matosd, Catarina Ferreirae, Ana Botelhof, Sofia Carvalhoc, Anaí Durazzog, Ana Faustinoh, Ricardo Ladeiras-Lopesi,j, Mariana Vasconcelosj,k, Catarina Vieiral, Miguel Correiam, António M. Ferreiran,o, Nuno Ferreirap, Gustavo Pires‐Moraisp, Ana G. Almeidaq, Maria João Vidigal Ferreirar, Madalena Teixeirap, em nome do GECNRMTC, do GEE e do GEFERC da SPC
a Faculdade de Medicina do Porto, Porto, Portugal
b Hospital da Luz, Setúbal, Portugal
c Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
d Hospital CUF Tejo, Lisboa, Portugal
e Centro Hospitalar de Trás-os-Montes e Alto Douro, Faculdade de Ciências da Saúde, Universidade da Beira Interior, Vila Real, Portugal
f Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
g Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz, Carnaxide, Portugal
h Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
i Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
j Faculdade de Medicina do Porto, Porto, Portugal
k Centro Hospitalar Universitário São João, Porto, Portugal
l Hospital de Braga, Braga, Portugal
m Centro Hospitalar Tondela/Viseu e Hospital CUF‐Viseu, Viseu, Portugal
n Centro Hospitalar de Lisboa Ocidental, Hospital de Santa Cruz, Carnaxide, Portugal
o Hospital da Luz, Lisboa, Portugal
p Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
q Centro Hospitalar Lisboa Norte, Hospital de Santa Maria e Faculdade de Medicina de Lisboa, Lisboa, Portugal
r Centro Hospitalar Universitário de Coimbra e Faculdade de Medicina, Universidade de Coimbra, Coimbra, Portugal
Received 04 October 2020. Accepted 29 October 2020
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Figures (4)
Show moreShow less
Tables (2)
Table 1. Symptom assessment and pre-test probability calculation (step 1).
Table 2. Guidance according to coronary computed tomography angiography results (CAD-RADS).
Show moreShow less
Additional material (1)
Abstract

Despite constant medical evolution, the reimbursement policy of the Portuguese National Health Service (NHS) for the study and risk stratification of coronary heart disease has remained unchanged for several decades. Lack of adjustment to contemporary clinical practice has long been evident. However, the recent publication of the European Guidelines for diagnosis and treatment of chronic coronary syndromes further highlighted this gap and the urgent need for a change. Prompted by these Guidelines, the Working Group on Nuclear Cardiology, Cardiac Magnetic Resonance and Cardiac CT, the Working Group on Echocardiography and the Working Group on Stress Pathophysiology and Cardiac Rehabilitation of the Portuguese Society of Cardiology, began a process of joint reflection on the current limitations and how these recommendations could be applied in Portugal. To this end, the authors suggest that the new imaging methods (stress echocardiogram, cardiac computed tomography and cardiac magnetic resonance), should be added to exercise treadmill stress test and myocardial perfusion scintigraphy in the available exam portfolio within the Portuguese NHS. This change would allow full adoption of European guidelines and a better use of tests, according to clinical context, availability and local specificities. The adoption of clinical guidance guideslines, based on these assumptions, would translate into a qualitative improvement in the management of these patients and would promote an effective use of the available resources, with potential health and financial gains.

Keywords:
Coronary heart disease
Risk assessment
Primary health care
Cardiovascular diagnostic techniques
Cardiac imaging techniques
Treadmill test
Computed tomography
Magnetic resonance
Echocardiography
Myocardial scintigraphy
Positron emission tomography
Guidelines
Resumo

Apesar dos avanços da medicina, há já várias décadas que os exames comparticipados pelo Serviço Nacional de Saúde (SNS) para o estudo e estratificação de risco da doença coronária se mantêm inalterados em cuidados de saúde primários. Apesar do desajuste à prática clínica contemporânea ser há muito evidente, a recente publicação das Recomendações Europeias para o diagnóstico e tratamento da síndrome coronária crónica veio realçar ainda mais este desfasamento e evidenciar a necessidade imperiosa de mudança na forma como são estudados estes pacientes em Portugal. No seguimento desta publicação, o Grupo de Estudo de Cardiologia Nuclear, Ressonância Magnética (RM) e Tomografia Computorizada (TC) Cardíaca, o Grupo de Estudo de Ecocardiografia e o Grupo de Estudos de Patofisiologia do Esforço e Reabilitação Cardíaca da Sociedade Portuguesa de Cardiologia iniciaram um processo de reflexão conjunta sobre as limitações atuais e a forma como poderiam ser aplicadas as recomendações internacionais no nosso país. Para tal, os autores sugerem que os novos métodos de imagem (ecocardiograma de esforço ou de sobrecarga, TC e RM cardíaca) se associem à prova de esforço e cintigrafia de perfusão do miocárdio no portfólio de exames oferecidos pelo SNS. Esta alteração permitiria uma plena adoção das recomendações europeias e uma melhor utilização dos meios, de acordo com o contexto clínico, a disponibilidade e as particularidades locais. A adoção de “normas de orientação clínica” baseadas nestes pressupostos traduzir‐se‐ia numa melhoria qualitativa na abordagem e otimização terapêutica destes pacientes, ao mesmo tempo em que potenciaria uma gestão eficaz dos recursos disponíveis, com potenciais ganhos de saúde e financeiros.

Palavras‐chave:
Doença coronária
Estratificação de risco
Cuidados de saúde primários
Técnicas de diagnóstico cardiovascular
Técnicas de imagiologia cardíaca
Prova de esforço
Tomografia computorizada
Ressonância magnética
Ecocardiografia
Cintigrafia de perfusão miocárdica
Tomografia de emissão de positrões
Recomendações
Full Text
Introduction

Cardiovascular (CV) diseases are the main cause of mortality and morbidity in Portugal. Among these, coronary heart disease (CHD), due to premature death or productive years of life lost (work and social life) and also as a result of the associated medical costs (intervention, pharmacotherapy, hospitalizations for acute coronary syndromes and heart failure), is particularly relevant in the Portuguese context.1,2

In about half of the cases, the first manifestation of CHD is acute myocardial infarction or sudden death,3 making it a disease and highlighting the need to invest particularly in prevention, rather than concentrating resources on the treatment of the acute phase. In recent decades, the evolution of medical treatment has resulted in a slow, but progressive, decrease in mortality both nationally and internationally. Even so, a large proportion of cases with irreversible damage could be prevented through early detection and timely correction of CV risk factors.

As CHD is a slowly evolving disease, it remains subclinical for much of an individual's life, meaning that if it is detected early, its natural evolution can be altered. Since 90% of the disease evolution can be justified by modifiable CV risk factors,4 there is an enormous potential for intervention, avoiding irreversible damage, such as a heart attack or sudden death. The primary objective of the NHS should be the promotion of CV health, through healthy lifestyles and identification of individuals at risk or with established CV disease. These patients may need specific therapies focusing on prognosis modification and improvement of quality of life.

National health service primary health care plays a central role in the promotion of CV health, screening of CV risk factors, detection of asymptomatic disease and therapeutic decision. Aware of the importance of primary health care in detecting and acting early on CV disease, it is expected that a general practitioner (GP) will be able to identify patients with increased CV risk or established subclinical disease, requiring specific therapies. For this, an appropriate use of the available diagnostic tools is essential, aiming at a high diagnostic and therapeutic efficiency and optimizing the existing resources.

Current status

Currently, with regard to the study of CHD or CV risk stratification, in primary health care, the GP may request tests on the NHS: a 12-lead electrocardiogram, an stress test or a myocardial perfusion scintigraphy (MPS). Using a request (P1 form), the doctor can refer the patient to a center with an agreement with the State for it to be performed.

Further cardiac assessment utilizing tests with high diagnostic performance, such as stress echocardiography (pharmacological or exercise), computed tomography coronary angiogram (CTCA) or stress/perfusion cardiac magnetic resonance (CMR) are excluded from the range of options; the government does not have commissioning agreements for these techniques, nor does it authorize GPs to request these tests directly for referral to public or private hospitals. Within the NHS, these tests can only be requested at the hospital, contributing to an increase in the burden on cardiology appointments for patients requiring coronary disease confirmation/exclusion exams. In a specialty where, due its nature, waiting lists have to be kept short—at the risk of timely medical care not being provided for potentially fatal short-term situations—the negative impact of these referrals should not be overlooked.

Why then is the system organized like this? At first glance, mainly financial sustainability issues come to mind. In fact, the electrocardiogram and stress test have a relatively low initial cost.5 However, the same is not true for MPS, the cost of which is similar, if not slightly higher than that of a stress CMR, and much higher than a stress echocardiogram, according to the NHS price tables, published in Government Legislation (“Diário da República”).5 In addition, the availability of MPS, as the only imaging test, leads to its usage for risk stratification or exclusion of CHD in patients with an intermediate/low or even low pretest probability.

Furthermore, cardiac CT has a significantly lower cost, both through risk stratification using coronary calcium quantification (calcium score)6—at a cost close to that of a stress test—or through the use of non-invasive CTCA for excluding coronary disease, costing 30% less cost than MPS.5 On the other hand, using an exercise test for the initial approach of a patient with suspected coronary disease, despite having a relatively low initial cost, can lead to increased costs, as a result of its low specificity/positive predictive value7 and the subsequent cascade of examinations it often leads to.

This issue has been well documented in cost-effectiveness studies,8–10 and is the main reason why the UK 2014 National Institute of Clinical Excellence clinical guideline and, more recently, the European Society of Cardiology guidelines,11 have stopped recommending this approach. Unlike the Portuguese NHS, these societies support a more cost-effective initial referral, based on imaging studies (particularly CTCA).12

In fact, the only reason explaining the current situation is purely historical: these were the modalities available in the 1970s and 1980s, when the NHS was established. Fortunately, in the last 40 years, medicine has evolved substantially, and several innovations have been introduced in hospital environment, a great contribution to the improvement of survival and quality of life of patients with coronary disease.

However, in primary health care, where most patients with CHD are being followed and, where efforts to fight the development and progression of coronary disease should be centralized, the tools have remained unchanged for 40 years.

It is our understanding that the current way of accessing cardiac testing in a primary care setting is not effective; it is expensive and does not suit the lower pretest probabilities of contemporary populations.13 It also contributes to a high rate of inappropriate referral to hospital cardiology appointments, with a potential negative impact on the waiting list for first appointments.

Therefore, it is essential to rethink the whole strategy of diagnosis and management of CV disease in a primary care setting, taking advantage of the efficacy and cost-effectiveness of all currently available diagnostic techniques.14

International roadmap to coronary heart disease diagnosis

Several European NHS have abandoned the use of a stress test has a first line test in this context, promoting a rational use of imaging based auxiliary diagnostic tests (ADT) and reserving stress test for situations in which specific additional information is needed.

The most recent European Guidelines for Chronic Coronary Syndromes, endorsed by the Portuguese Society of Cardiology (RPC), which are the reference guidelines for Portugal, follow the same train of thought and advise against a stress test as first line in the diagnosis of CHD, not only because of its poor performance in disease rule in/rule out (almost always requiring additional tests, delaying diagnosis, increasing costs), but also because it can be a source of patient anxiety with false positive tests and, perhaps even more importantly, leading to a dangerous false confidence in patients with a false negative test.15

These Guidelines, published in September 2019, highlighted the enormous gap between Portuguese common practice and evidence-based international medical practices concerning CHD diagnosis. The aforementioned guidelines were the major driving force behind the present position paper between three different Study Groups of the RPC, which together are willing to change the Portuguese ‘status quo’. Currently, a Portuguese GP cannot have access to the best evidence-based medicine to diagnose and consequently treat CHD, without overloading hospital outpatient units, or alternatively, referring their patients with a suspicion of CHD, for single-photon emission computed tomography (SPECT), which may be not the most adequate indication.16

Gender difference and inequality

Being a woman poses an even greater problem in current medical practice in this field, mainly because these tests have a worse performance in women. Concerning the stress test, several studies, mainly in male populations, have proven that sensitivity and specificity in female gender are only slightly over 50%.17–19 On the other hand, SPECT exposes patients to ionizing radiation (especially relevant in women of childbearing age) and can have a lower performance in female due to lower spatial resolution and breast attenuation artifacts.16,20–22

Redefining the role of the stress testRecommendations for rational use, according to current scientific evidence

After the publication of the guidelines for diagnosis and management of chronic coronary syndromes, it is necessary to redefine the role of the stress test in Portuguese reality. Thus, the approach and algorithms proposed in this document do not intend its indiscriminate use for the assessment of CHD and CV risk stratification, but they also do not imply its exclusion for use in the appropriate clinical context. On the contrary, the stress test has unique characteristics that makes it an important option among the exams for coronary artery disease assessment. Its role is not limited to the detection of CHD, when imaging tests are not available (class IIb, level of evidence B), or in the re-stratification of clinical probability, as suggested by the guidelines.11 Its diagnostic value, prognosis and impact on clinical decision is well established in different areas of cardiology, which transcend the objective of this document, including evaluation of athletes, evaluation and monitoring in clinical rehabilitation programs, evaluation of patients with exercise-induced arrhythmias, assessment of functional capacity and symptom development, both in coronary, valvular or congenital patients.23

Recomended process

Our Study Groups took the most recent European guidelines (Chronic Coronary Syndromes, Dyslipidemia and CV risk stratification) as a basis to develop referral standards for ADT that can be adapted to the Portuguese context. A committee of initial writers was nominated (AF and RLL for CV risk stratification in asymptomatic patients and AB, CF and MV for the suspicion of coronary disease), who then presented their proposals to the other authors of these recommendations.

Based on this initial work, adequate referral scenarios were created for ADT and also recommended subsequent guidance, based on test results.

Carrdiovascular risk stratification in asymptomatic patients

In the context of primary health care, CV risk stratification in asymptomatic patients is particularly relevant. Patients with higher vascular risk should be identified in order to initiate proper prevention strategies, while avoiding overtreatment of patients with lower CV risk, who do not benefit from more intensive therapeutic therapies and who may suffer from side effects. Patients >40 years old should be stratified according to the European risk SCORE.6,24

In individuals at moderate CV risk, and in selected cases of low risk according to this initial assessment, the coronary calcium score result can assist in risk re-stratification to high or low, serving as a valuable tool in guiding therapeutic decision. Indeed, coronary calcium score is a marker of individual coronary atherosclerotic burden resulting from the interaction of different CV risk factors, and has proved to be cost-effective in guiding statin therapy compared to the strategy of treating all patients.25 Considering this, it appears to be particularly relevant in the decision to initiate statins26 and in the definition of the therapeutic target of low-density lipoprotein (LDL) cholesterol lowering, according to the most recent guidelines of the European Society of Cardiology.27Fig. 1 represents the decision and guidance flowchart in the context of CV risk stratification in asymptomatic individuals.

Figure 1.

Recommendations for cardiovascular risk stratification in asymptomatic patients.

(1) Systematic assessment of CV risk score in ages <40 and in absence of known CV risk factors is not recommended, except in some specific groups in which evaluation of the risk may be considered (e.g. aviation pilots, heavy vehicle drivers).

(2) Risk evaluation repeated every five years (indicative period, subject to change).

(3) Consider noninvasive functional study if symptoms suggestive of CHD.

Legend: ASA: acetylsalicylic acid; CaSc: calcium score; CV: cardiovascular.

(0.36MB).

After calculation of European risk SCORE, additional CV risk stratification with calcium score may be indicated in patients at moderate risk (SCORE ≥ 1% and <5%), in those with indication for a statin, but reluctant to do so and in patients with low CV risk (SCORE < 1%) in presence of other cardiovascular risk factor (CVRF) not included in SCORE risk chart (young person with diabetes – type. 1 < 35 years of age, type 2 0 years of age), premature CHD in 1 st degree Family member [♂ <55 years; ♀ <60 years], systemic inflammatory disease (rheumatoid arthritis, systemic erythematous lupus, HIV), premature menopause (<40 years), previous thoracic radio or chemotherapy, psychiatric disease, and obstructive sleep apnea).

On the other hand, additional risk stratification in asymptomatic patients with documented CV disease and patients with a very low (SCORE <1% without other CVRF and without an indication for hypolipidemic pharmacological therapy) or high/ very high CV risk (SCORE ≥5%, diabetes ≥10 years or with another associated CVRF or target organ damage, familial hypercholesterolemia and chronic renal disease) – as for these patients the strategy will not significantly change based on the test result.

A calcium Score of zero identifies patients with a very low mid-term risk of coronary events and confirms or re-stratifies the low risk group (except if diabetic), where maintaining or promoting a healthy lifestyle is recommended. A calcium score of 1–99 identifies patients with intermediate mid-term risk of coronary events, with a recommendation of lifestyle modification a statin may be considered if the percentile is 50–74 (LDL cholesterol level target <100 mg/dl). A calciums score ≥100 or percentile ≥75 for age and gender is associated with an increased risk of mid-term coronary events, and initiating a statin (with the objective of reducing LDL cholesterol ≥50% and a target of <70 mg/dL) is advised; although less well established, it may be adequate to also consider acetylsalicylic acid (ASA) if percentile ≥75. A calcium score >400 identifies patients with a very increased mid-term risk of coronary events, for whom a statin and ASA should be considered; in this group it is particularly important to confirm the absence of symptoms (in case of symptoms suggestive of ischemia, consider referral for functional studies).

Coronary calcium score is indicated especially in risk re-stratification of asymptomatic individuals, so it should not be used in an isolated manner in symptomatic patients with a suspicion of chronic coronary syndrome. However, as well as the stress test, it can be used form of re-stratifying clinical probability in that context (see decision fluxogram for suspicion of coronary disease – Fig. 2).

Figure 2.

Decision algorithm according to pre-test probability/clinical likelihood (steps 2A and 2B).

CAD: coronary artery disease; CaScore: calcium score; CMR: cardiac magnetic resonance; CT: computed tomography; CV: cardiovascular; LV: left ventricle; LVEF: left ventricle ejection fraction; PET: positron emission tomography; PTP: pre-test probability; SPECT: single photon emission computed tomography.

(0.39MB).
Cardiovascular risk stratification in symptomatic patients

In symptomatic patients, ADT may be indicated to confirm or exclude the presence of coronary artery disease, in order to initiate appropriate therapy. In the initial assessment of these patients, pretest probability of coronary disease, based on age, sex and symptoms should be determined (Table 1). An analytical study with blood count, creatinine, lipid profile, fasting glucose and HbA1c should also be performed, as well as a rest electrocardiogram and a transthoracic echocardiogram.

Table 1.

Symptom assessment and pre-test probability calculation (step 1).

1.1 - Which symptoms should be valued?
Do symptoms have suspicious/ anginal characteristics
Typical anginaFulfills the 3 characteristics: 
1-Oppressive/constricting discomfort in the chest or in the neck, jaw, shoulder or arm 
2-Triggered by physical exercise 
3-Relieved by rest or nitrates in 5 min. 
Atypical angina  Meets 2 of the previous characteristics. 
Non-anginal chest pain  Only meets 1 or none of the above. 
1.2 What is the probability of a patient with these symptoms having coronary heart disease?
  Typical anginaAtypical anginaNon-anginal painDyspnea
Age  Men  Women  Men  Women  Men  Women  Men  Women 
30−39  3%  5%  4%  3%  1%  1%  0%  3% 
40−49  22%  10%  10%  6%  3%  2%  12%  3% 
50−59  32%  13%  17%  6%  11%  3%  20%  9% 
60−69  44%  16%  26%  11%  22%  6%  27%  14% 
>70  52%  27%  34%  19%  24%  10%  32%  12% 

Traditional clinical classification of suspected anginal symptoms.

Pre-test probability of coronary heart disease according to age, gender and symptoms.

The detection of a left ventricular ejection fraction below 50%, especially if associated with wall motion abnormalities, determines a very high probability of coronary artery disease, and justifies a direct referral to a cardiology consultation. Although additional tests, such as stress test and/or coronary calcium score, are not mandatory, European guidelines recommend their integration into the decision algorithm, particularly as modifiers of clinical probability in patients with intermediate pretest probability (based on age, sex and symptoms) (Fig. 2A). Therefore, performing these tests must be considered on an individual basis. Chest X-ray may also be an important ADT in cases of atypical chest pain or dyspnea for screening for pulmonary disease.

Integration of pretest probability of coronary artery disease with the result of ADT described above (electrocardiogram, echocardiogram, laboratory study and eventually, exercise test and calcium score) determines clinical probability of coronary artery disease (Fig. 2). If clinical probability is low (≤15%), there is no indication for further investigation. If it is higher, imaging tests are indicated to exclude or confirm the diagnosis and stratify the risk for coronary events. These tests must be selected according to their advantages and limitations, patient characteristics and local availability7 (Table A – supplemental material). Two strategies are possible: 1. an anatomical evaluation, performing a coronary computed tomography angiography (CTA) or 2. a functional evaluation, through tests that can detect myocardial ischemia. While the former provides information about the atherosclerotic process and is particularly effective in ruling out disease, in patients with lower probabilities, the latter provides information about the impact of the disease on blood distribution to the myocardium and is particularly useful in the decision to revascularize in patients with higher probability or with known coronary artery disease. Both proved to be clinically useful and able to favorably influence the prognosis of these patients.28,29

The correct use of these tests and subsequent guidance according to their results (see Table 2 for guidance according to CTA result and Fig. 3 for guidance according to results from ischemia tests) will ensure high diagnostic accuracy, optimization of individualized therapy and a low rate of inappropriate referrals to hospital cardiology consultations.

Table 2.

Guidance according to coronary computed tomography angiography results (CAD-RADS).

CAD-RADS  Maximum stenosis  Interpretation  Additional evaluation?  Proposed orientation 
0  0 (absence of plaques)  Absence of CD  No  Tranquilization. Consider non-atherosclerotic causes for symptomatology 
1<25% (no stenosis/minimal stenosis)Minimal CD, non-obstructiveNoConsider non-atherosclerotic causes for symptomatology 
Consider preventive therapy and CVRF modification 
2  25−49% (mild stenosis)  Mild CD, non-obstructive  No  Consider non-atherosclerotic causes for symptomatology Consider preventive therapy and CVRF modification 
3  50−69%  Moderate stenosis  Consider functional study (CMR, stress echo or scintigraphy)  Consider symptom-guided anti-ischemic therapy, preventive therapy and CVRF modification 
4A - 70−99%  Severe stenosisA- Consider functional study or referral to hospital cardiology  Symptom guided anti-ischemic therapy 
B - LM > 50% or 3 vessels ≥70%B- Referral to cardiologyPreventive therapy and CVRF modification 
Consider referral to hospital cardiology 
5100% (total occlusion)Coronary occlusionReferral to cardiologySymptom guided anti-ischemic therapy. 
Preventive therapy and CVRF modification. 
Referral to hospital cardiology 
N  Non diagnostic  Obstructive CD cannot be excluded  Additional/alternative evaluation may be necessary   

Modifiers CAD-RADS: S: Stent; G: Coronary bypass graft; V: plaque with vulnerability characteristics.

Figure 3.

Algorithm proposal for guidance according to imaging functional test results for detection of ischemia.

(1) For pharmacological treatment of symptoms of angina/dyspnea look for recommendations for this subject (pages 432–433, 2019 European Society of Cardiology Guidelines for the diagnosis and management of chronic coronary syndromes. European Heart Journal (2020) 41, 407-477).

(2) As for any other test, there are results that may correspond to a false positive or a false negative. If the result is negative, and excluded any other potential causes for patient symptoms, other test may be considered, according to patient pre-test probability as a guidance to support this decision. It may be considered a different test from the initial one.

(To select the appropriate test, consult table A from supplemental material “Characteristics of main imaging tests for assessment of coronary disease”)

(0.36MB).

Fig. 4 summarizes the approach that we propose for the study of symptomatic patients with suspected coronary artery disease, in the context of primary health care. In our opinion this model, which follows the current European recommendations, would be easily applicable in Portugal and has a great potential to optimize resources in a cost-effective way.

Figure 4.

Summarized algorithm decision in suspected coronary disease.

PTP: Pre-test probability.

(To select the appropriate test, consult table A from supplemental material “Characteristics of main imaging tests for assessment of coronary disease”)

(0.32MB).
Future perspectives

We believe that this strategy can be implemented with great success in Portugal, through national guidelines (“Normas de Orientação Clínica”), scientifically evidence-based and managed according to available resources.

We hope that this consensus document, based on expert opinion in the field, can be the driving force for a much-needed discussion in Portugal and stimulate a reflection on the primary care strategy in the CV area, with a particular focus on diagnosis and guidance for coronary artery disease.

Steps toward change

The degree of mismatch between our reality and international guidelines is now so obvious that the need for a changing policy in this area looks inevitable. Several strategies can be studied, in order to overcome this mismatch and the process we are putting forward is just one of many possible solutions, if we maintain the present primary care operating principles in the NHS. Other strategies, however, may be viable, for example patient direct referral for ADT in a local hospital environment, at the request of a GP, or centralizing the whole process in NHS hospitals.

In spite of the evidence on cost-effectiveness coming from other scenarios, we believe that a national based analysis should be mandatory. This analysis should be promoted by the government, allowing decisions to be based, not only on scientific evidence, but also on local feasibility. In some countries, a change in paradigm took place with the compromise of not increasing costs in coronary artery disease diagnosis. We can follow these good examples and define the best strategy to achieve the same objectives, with better healthcare for the population, without an additional cost charge for NHS. This approach goes, obviously, beyond the scope of this document and the capabilities of this expert group.

Even so, the Study groups in Nuclear Cardiology, Magnetic Resonance and Cardiac Computed Tomography, Echocardiography and Pathophysiology of Exercise and Cardiac Rehabilitation of the Portuguese Society of Cardiology would like to show their interest in participating in any forthcoming change in process discussion, if the competent authorities so wish.

Obstacles and resistance

Beyond a small resistance to initial change, mostly based on less familiarity with the indications, contraindications, advantages, and disadvantages of “new” diagnostic techniques for coronary artery disease, wide acceptance is anticipated and quick adoption of new recommendations by general physicians from the NHS. Many of them already use international recommended strategies, namely European guidelines in patients who have other healthcare subsystems, such as the government funded healthcare program for civil servants (ADSE) or insurance, as among these citizens physicians have been able to follow these recommendations for a long time (for example, tests like stress echo, cardiac CT or CMR are co-paid in these subsystems).

Greater resistance is anticipated from centers with NHS agreements for exams like stress test or MPS. The first one, stress test, because on a long-term basis, although its role will be maintained for specific groups and clinical scenarios, it will lose part of its importance in the initial approach and diagnosis of coronary artery disease. The second one because, although it will keep its current indication, it will no longer be the only exclusive imaging test on the NHS. Even so, a gradual adaptation to the new scenario anticipated, with the first one expanding its indication to exercise or pharmacological stress echo and the second one to include CTA and CMR exams as a diagnostic alternative.

Discussion/Conclusion

Clinical practice, forced by the present NHS organization in terms of CV ADT access within primary healthcare, is frankly out of date and enhances inefficiencies that are transmitted along the healthcare chain, with potential overload on the hospital system. There is an urgent need to change the CV stratification paradigm and the evaluation of patients with suspected coronary artery disease in Portugal, following evidence-based medicine and international clinical recommendations.

Over the next few years there will be a need for new updates, including results from recent studies, with a huge potential to modify current strategies, especially the results coming from the ISCHEMIA TRIAL.30,31 Also, for this reason (but not only), the purpose of this document is not to propose a new closed model for another 40 years of the NHS – which would quickly become as obsolete as the present one. On the contrary, its main purpose is to encourage the development of a new concept of constant monitoring (re)appraisal and updating of processes. It is only in this way that we will achieve quality medicine in the CV area, reconciling, in an efficient way, the best scientific knowledge with the limited resources available.

Appendix A
Supplementary data

The following is Supplementary data to this article:

References
[1]
C. Fonseca, D. Brás, I. Araújo, et al.
Heart failure in numbers: estimates for the 21st century in Portugal.
Rev Port Cardiol, 37 (2018), pp. 97-104
[2]
Direção-Geral da Saúde (DGS). In: Portugal - Doenças Cérebro-Cardiovasculares em Números – 2015. Programa Nacional para as Doenças Cérebro-Cardiovasculares; 2015 [acedido em 2020, Janeiro]. Available at: https://www.dgs.pt/estatisticas-de-saude/estatisticas-de-saude/publicacoes/portugal-doencas-cerebro-cardiovasculares-em-numeros-2015-pdf.aspx.
[3]
B. Ibanez, S. James, S. Agewall, et al.
2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC).
Eur Heart J, 39 (2018), pp. 119-177
[4]
S. Yusuf, S. Hawken, S. Ôunpuu, et al.
Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.
[5]
Diário da República, 1.a série—N.o 132—11 de julho de 2017.
[6]
M. Fiepoli, A. Hoes, S. Agewall, et al.
2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR).
Eur Heart J, 37 (2016), pp. 2315-2381
[7]
J. Knuuti, H. Ballo, L. Juarez-Orozco, et al.
The performance of non-invasive tests to rule-in and rule-out significant coronary artery stenosis in patients with stable angina: a meta-analysis focused on post-test disease probability.
Eur Heart J, 39 (2018), pp. 3322-3333
[8]
J.A. Ladapo, F.A. Jaffer, U. Hoffmann.
Clinical outcomes and cost-effectiveness of coronary computed tomography angiography in the evaluation of patients with chest pain.
J Am Coll Cardiol, 54 (2009), pp. 2409-2422
[9]
A.M. Ferreira, H. Marques, P.A. Gonçalves, et al.
Cost-effectiveness of different diagnostic strategies in suspected stable coronary artery disease in Portugal.
Arq Bras Cardiol, 102 (2014), pp. 391-402
[10]
L.H. Nielsen, N. Ortner, B.L. Nørgaard, et al.
The diagnostic accuracy and outcomes after coronary computed tomography angiography vs. conventional functional testing in patients with stable angina pectoris: a systematic review and meta-analysis.
Eur Heart J Cardiovasc Imaging, 15 (2014), pp. 961-971
[11]
J. Knuuti, W. Wijns, A. Saraste, et al.
2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes: the Task Force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology (ESC).
Eur Heart J, 41 (2020), pp. 407-477
[12]
A. Timmis, C.A. Roobottom.
National Institute for Health and Care Excellence updates the stable chest pain guideline with radical changes to the diagnostic paradigm.
[13]
L.E. Juarez-Orozco, A. Saraste, D. Capodanno, et al.
Impact of a decreasing pre-test probability on the performance of diagnostic tests for coronary artery disease.
Eur Heart J Cardiovasc Imaging, 20 (2019), pp. 1198-1207
[14]
R. Kwong, Y. Ge, K. Steel, et al.
Cardiac magnetic resonance stress perfusion imaging for evaluation of patients with chest pain.
J Am Coll Cardiol, 74 (2019), pp. 1741-1755
[15]
M.F. Alves, A.M. Ferreira, G. Cardoso, et al.
Probabilidade teórica de doença coronária pré- e pós-teste em duas estratégias diagnósticas - Contributo relativo da prova de esforço e da angio-TC cardíaca.
Rev Port Cardiol, 32 (2013), pp. 211-218
[16]
P.S. Douglas, U. Hoffmann, M.R. Patel, et al.
Outcomes of anatomical versus functional testing for coronary artery disease.
N Engl J Med, 372 (2015), pp. 1291-1300
[17]
A.P. Morise, G.A. Diamond.
Comparison of sensitivity and specificity of exercise electrocardiography in biased and unbiased populations of men and women.
Am Heart J, 130 (1995), pp. 741-747
[18]
B.L. Kumar, E. Bhuvaneshwari.
Correlation of treadmill stress test with coronary angiography to predict coronary artery disease in males versus females.
Indian J Cardiovasc Dis Women-WINCARS, 2 (2017), pp. 25-28
[19]
S. Greulich, O. Bruder, M. Parker, et al.
Comparison of exercise electrocardiography and stress perfusion CMR for the detection of coronary artery disease in women.
J Cardiovasc Magn Reson, 14 (2012), pp. 36
[20]
J.P. Greenwood, M. Motwani, N. Maredia, et al.
Comparasion of cardiovascular magnetic resonance and single-photon emission computed tomography in women with suspected coronary artery disease from the clinical evaluation of magnetic resonance imaging in coronary artery disease (CE-MARC) trial.
Circulation, 129 (2014), pp. 1129-1138
[21]
F.M. van der Zant, M. Wondergem, S.V. Lazarenko, et al.
Ruling out coronary artery disease in women with atypical chest pain: results of calcium score combined with coronary computed tomography angiography and associated radiation exposure.
J Womens Health, 24 (2015), pp. 550-556
[22]
N. Pagidipati, K. Hemal, A. Coles, et al.
Sex differences in functional stress test versus CT angiography in symptomatic patients with suspected CAD: insights from PROMISE.
J Am Coll Cardiol, 67 (2016), pp. 2607-2616
[23]
M.E. Tavel.
Stress testing in cardiac evaluation – current concepts with emphasis on the ECG.
Chest, 119 (2001), pp. 907-925
[25]
J.C. Hong, R. Blankstein, L.J. Shaw, et al.
Implications of Coronary Artery Calcium Testing for Treatment Decisions Among Statin Candidates According to the ACC/AHA Cholesterol Management Guidelines.
JACC Cardiovasc Imaging, 10 (2017), pp. 938-952
[26]
S.M. Grundy, N.J. Stone, A.L. Bailey, et al.
2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
Circulation, 139 (2019), pp. e1082-e1143
[27]
F. Mach, C. Baigent, A.L. Catapano, et al.
2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk.
Eur Heart J, 00 (2019), pp. 1-78
[28]
The SCOT-HEART Investigators.
Coronary CT angiography and 5-year risk of myocardial infarction.
N Engl J Med, 379 (2018), pp. 924-933
[29]
E. Nagel, J.P. Greenwood, G.P. McCann, et al.
Magnetic Resonance perfusion or fractional flow reserve in coronary disease.
N Engl J Med, 380 (2019), pp. 2418-2428
[30]
D.J. Maron, J.S. Hochman, H.R. Reynolds, et al.
Initial invasive or conservative strategy for stable coronary disease.
N Engl J Med, 382 (2020), pp. 1395-1407
[31]
J.A. Spertus, P.G. Jones, D.J. Maron, et al.
Health-status outcomes with invasive or conservative care in coronary disease.
N Engl J Med, 82 (2020), pp. 1408-1419

Please cite this article as: Bettencourt N, Mendes L, Fontes JP, Matos P, Ferreira C, Botelho A, et al. Documento de Consenso sobre Estratificação de Risco Cardiovascular e estudo da doença coronária em Portugal: a posição dos Grupos de Estudo de Cardiologia Nuclear, Ressonância Magnética e Tomografia Computorizada Cardíaca, de Ecocardiografia e de Fisiopatologia do Esforço e Reabilitação Cardíaca. Rev Port Cardiol. 2021. https://doi.org/10.1016/j.repc.2020.10.009

Idiomas
Revista Portuguesa de Cardiologia (English edition)

Subscribe to our newsletter

Article options
Tools
Supplemental materials
en pt

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos

By checking that you are a health professional, you are stating that you are aware and accept that the Portuguese Journal of Cardiology (RPC) is the Data Controller that processes the personal information of users of its website, with its registered office at Campo Grande, n.º 28, 13.º, 1700-093 Lisbon, telephone 217 970 685 and 217 817 630, fax 217 931 095, and email revista@spc.pt. I declare for all purposes that the information provided herein is accurate and correct.