Guidelines on the Management of Stable Coronary Artery Diseases
Prof. Dr. Udo Sechtem
Chief, Division of Cardiology and Pulmology
Robert Bosch Hospital
HealthManagement Editorial Board member
As Director of Department of Cardiology and Pulmonology at Stuttgart’s Robert- Bosch-Krankenhaus in Germany, Prof. Dr. Udo Sechtem is one of the Chairpersons of the Task Force that developed the 2013 ESC Guidelines. HealthManagement spoke to him about the role of medical imaging in the diagnosis of stable coronary artery disease (CAD).
Professor Sechtem, what motivated the ESC to revise the guidelines previously in effect?
The ESC has the policy to revise guidelines every 4-6 years. Hence, the 2006 guidelines were up for revision. Of course, the field has moved forward considerably in the meantime and a lot of new publications needed incorporating.
It appears that ECG should no longer be the initial test of choice in the diagnosis of CAD. How important are the advancements made in medical imaging technology for these recommendations?
It is in fact the ECG itself with its suboptimal test properties which induced us to limit the role of the ECG in the current guidelines. Nevertheless, the ECG is still a good technique as long as the pretest probability of patients with suspected stable CAD is below 65%. The low sensitivity of about 50% of the exercise stress ECG makes testing at higher pretest probabilities, however, not useful. This is because at such high pretest probabilities the number of false negative tests will become unacceptably high. In contrast, all imaging techniques have a better sensitivity and are hence better especially for patients at pretest probabilities between 65 and 85%. Above a pretest probability of 85% all testing will result in increasing numbers of false negatives which led us to recommending no additional testing in those patients (elderly males with typical angina) for the purpose of making the diagnosis of stable CAD.
The new guidelines place an unprecedented emphasis on local expertise available in each health centre. Will this not be of disadvantage to those not equipped with the latest imaging systems?
It is not necessary to have the “latest imaging systems”. More important than the latest equipment is the local expertise which refers mainly to the interpretation skills of those performing the test. However, for coronary CTA a 64-line state-of-the-art CT is required.
The recommended revised diagnostic algorithm for diagnosing CAD is now relying on pretest probability. Why is this so significant?
Pretest probability has always had a role in choosing the right diagnostic tool. However, in the previous guideline of the ESC this role was not as explicitly defined as it is now. Pretest probability as outlined already above when discussing the exercise stress ECG is important for optimal use of health resources. For instance, a young lady with atypical chest pain has such a low probability of stenosing CAD that performing any test will more likely result in a false (false positive) test result than when assuming that she has nostenosing CAD on the basis of a pretest probability being smaller than 15%.
How have these new guidelines been received in practice? Has the ESC collected any feedback from cardiologists who have already adopted them?
The process of adopting guidelines is a long one and a lot of educational effort is needed to popularise the guidelines. Until now we have had some educational sessions at the ESC Congress in Amsterdam and a Webinar has been broadcast and is now available online (http://www.escardio.org/education/eLearning/webinars/general- cardiology/recordings/Pages/patient-with-stable-angina.aspx). Another Webinar will be broadcasted in December 2013 led by Professor Gilles Montalescot and it will focus on the therapeutic aspects of this guideline.
What are your predictions for the future with regards to medical imaging and disease diagnosis?I am afraid that we physicians will lose our free choice of test frequencies and test modalities in the future. The expenses for medical imaging have risen so dramatically that some restrictions by authorities will likely apply to our future choices.