Ischaemic heart disease

Call to curb inappropriate coronary angiography


A leading Adelaide cardiologist who has spearheaded new guidelines for the treatment of acute coronary syndrome says more needs to be done to curb the inappropriate use of coronary angiography in Australia.

Professor Derek Chew, an interventional cardiologist and Professor of Cardiology at Flinders University, was talking to the limbic on the eve of the Cardiac Society of Australia and New Zealand’s annual scientific meeting in Adelaide.

He said coronary angiography was effective in patients in the acute stage, it was less effective as a treatment for patients outside this setting, including patients with non-acute coronary artery disease (CAD).

“We have an underuse problem in those who need it and an over use problem in those who don’t need it,” Professor Chew said.

“We can actually show that there is an association between angiography in an acute setting and (better) survival rates.”

Professor Chew co-authored a paper published this week in the MJA, which looked at the variation in coronary angiography rates in Australia, in relation to socio-demographic, health service and disease burden indices. This week’s MJA also reveals details of the new ACS treatment guidelines, developed by a team headed by Professor Chew.

“Significant variation in providing coronary angiography, not related to clinical need, is evident across Australia,” the authors wrote. “A greater focus on clinical care standards and better distribution of health services will be required if these disparities are to be reduced.”

The authors also said their findings suggested that health reforms aimed at the appropriate use of diagnostic coronary angiography may be required to improve consistency and equity of access, and consequently to deliver positive outcomes for the Australian community more efficiently.

“While there is no current guidance on stable CAD in Australian, criteria for the appropriateness of angiography and revascularisation have been developed in the US. It is notable that re-imbursement by Medicare and Medicaid in the US for the costs of invasive procedures is now linked to these appropriateness criteria,” they wrote.

“It is suggested that funding linked to the appropriateness of care or the achievement of clinical care standards, and limiting re-imbursement for angiography in low value clinical situations, should be focuses of debate in any health care reform discussion in Australia.”

Professor Chew conceded that this position would not likely be embraced wholeheartedly by the entire Australian cardiology community, but it was important to ensure that coronary angiography was being used appropriately.

“We’re all taxpayers and the cost of healthcare is increasing,” he told the limbic. “We need to ensure the right patients are getting the appropriate treatments.”

Added to this, he said it was important that non-acute patients were also given access to other effective treatments such as medications and lifestyle changes, and then monitored regularly rather than taking the ‘quick fix’ option of angiography, which might not even be the appropriate treatment for every patient.

“That instant fix is also very expensive,” he said.

New guidelines for ACS simplify advice

Professor Chew and colleagues from around Australia also this week released new guidelines for the treatment of acute coronary syndrome (ACS), published in the CSANZ’s journal Heart, Lung and Circulation.  An executive summary was also published in the MJA.

The National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand guidelines are designed to simplify advice to doctors regarding the target time for myocardial reperfusion in patients presenting with an ST-elevation myocardial infarction.

The guidelines provide advice on standardised assessment and management of suspected ACS regarding diagnosis and risk stratification of ACS; provision of acute reperfusion therapy and immediate post-fibrinolysis care for patients with ST-segment elevation myocardial infarction; risk stratification informing the use of routine versus selective invasive management for patients with non-ST segment elevation ACS; administration of antithrombotic therapies in the acute setting and considerations affecting their long-term use; and implementation of an individualised secondary prevention plan that includes both pharmacotherapies and cardiac rehabilitation.

Writing an accompanying editorial in the MJA, Associate Professor Andrew MacIsaac from St Vincent’s Hospital in Melbourne, said the revised guidelines simplified the target time for myocardial reperfusion in patients presenting with an ST-elevation myocardial infarction.

He said that while data showed survival rates were historically better, there was “still much room for improvement”.

He also reiterated the importance of secondary prevention strategies improve outcomes following a cardiac event.

“Secondary prevention is traditionally overseen in a cardiac rehabilitation program,” he wrote.

“Only a minority of patients attend such programs, and a significant number do not continue with guideline-recommended therapy and lifestyle modifications.”

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