Improving adherence to guidelines in the management of chronic coronary syndrome with index presentation through cardiology clinic resulting in invasive procedure: a quality improvement project

Background

Clinical history is the cornerstone for diagnosing chronic coronary syndrome (CCS) and the classification of patients according to the character of chest pain. Current guidelines recommend Computed Tomography Coronary Angiogram (CTCA) for patients with a low clinical likelihood of Coronary Artery Disease (CAD) and no prior history. Furthermore, optimised medical therapy (OMT) should be established prior to any invasive strategy.

Purpose

To evaluate and improve the management of angina in patients and ongoing invasive treatment, to assess the proportion of angina patients who need a Percutaneous Coronary Intervention (PCI), and to reduce unnecessary invasive procedures through a two-cycle quality improvement audit in patients with an index presentation of CCS.

Methods

Cycle 1 (Baseline): A cohort of 262 patients was screened over four months. Inclusion criteria specified patients with no prior CAD history were evaluated through the cardiology chest pain clinic. The number of included patients with index presentation chest pain was 160. Data was collected through descriptive analysis, and the patients were interviewed face-to-face.

Intervention: Following Cycle 1 findings, we implemented a "Guideline-Directed Referral Checklist," conducted educational workshops for physicians on OMT titration, and established a streamlined pathway for CTCA.

Cycle 2 (Re-audit): A subsequent cohort of 140 patients was audited using the same inclusion criteria to measure the impact of these interventions.

Results

In the first cycle; Over 50% were current or former smokers, and hyperlipidemia (63.1%) was the most prevalent comorbidity. Only 17.5% of patients were prescribed two anti-anginal drugs prior to Coronary Angiography (CAG) or PCI. Non-invasive imaging (that was CTCA or stress echocardiography) was performed in only 13.1% of cases; the majority (82.5%) proceeded directly to CAG or PCI without non-invasive imaging. Notably, 74.3% of patients who underwent CAG were found to have non-cardiac chest pain. Regarding interventions, 20.6% required revascularisation (16.2% PCI; 4.4% CABG). The comparison between the two cycles demonstrated a significant shift toward guideline-directed care, as illustrated in Table 1.

Furthermore, the proportion of smokers receiving no cessation counselling decreased from 24.6% to 9.8%. The "negative" CAG rate in patients who had prior non-invasive imaging dropped to near zero.

Conclusion(s)

OMT is frequently underutilised prior to non-invasive or invasive investigation. Physicians should prioritise OMT and non-invasive screening according to guidelines before referring to a cardiology clinic. On the other hand, directing patients toward CAG or PCI can reduce the duration of waiting and expedite a definite diagnosis without requiring multiple modalities of non-invasive imaging. A primary limitation of this study was the selection bias toward patients who ultimately received CAG or PCI.Table 1