At least 56 000 patients with angina in the UK who should have had a computed tomography coronary angiography (CTCA) scan last year missed out because of a shortage of scanners and radiologists, say the Royal College of Radiologists and the British Society of Cardiovascular Imaging.
They warn that underlying heart conditions may be missed if patients presenting with chest pain have their heart function assessed by exercise tests rather than CTCA scans. The National Institute for Health and Care Excellence (NICE) updated its guideline in 2016 to recommend that all patients with chest pain should be investigated using CTCA.1
A Scottish study published this year in the New England Journal of Medicine found that investigating patients with stable chest pain by using CTCA nearly halved their risk of death from coronary heart disease or their risk of non-fatal myocardial infarction over the next five years.23
Figures from NHS Digital show that 75 791 CTCA scans were performed in the UK last year. However, the Royal College of Radiologists and the British Society of Cardiovascular Imaging estimate that this number should have been at least 132 080 if NICE guidelines had been followed, indicating a shortfall of 43%.
The researchers calculated this higher figure by looking at the number of rapid access chest pain clinic referrals and estimating that 90% of the patients referred should receive a scan, as 10% of referred patients do not have suspected angina.
UK provision of CTCA scans was best in England, where 69 865 CTCA scans were performed in 2017. However, the researchers calculated that at least 111 239 scans should have been done—a 37% shortfall. Wales had an estimated 4854 patients who missed out on scans last year (78% shortfall), Scotland had 7900 (73% shortfall), and Northern Ireland had 2162 (58% shortfall).
Andy Beale, the Royal College of Radiologists’ medical director for membership and business, told The BMJ, “In the last 10 years it has become possible to take a CT scan of the heart in between beats when it is stationary. You can now get excellent pictures of the coronary arteries and look for plaque, calcification, atherosclerosis, and narrowing of the arteries.”
Beale, a consultant radiologist at Great Western Hospitals NHS Foundation Trust, added, “Exercise tests are not particularly accurate and result in a lot of patients being either wrongly labelled or wrongly treated. Cardiac CT scans are more than 95% accurate at diagnosing, and even better at ruling out, coronary artery disease.
“There used to be worries about the radiation dose with CT scans, but it is roughly 10% of what it used to be. The dose is now not that dissimilar to a number of chest x rays and is significantly less than an angiogram.”
For every million people the UK has only nine CT scanners, while France has 17 and Germany has 35. In addition, many of the UK’s existing CT scanners are not modern enough to perform CTCAs and need to be updated, said the royal college. A new scanner costs around £700 000-£1m (€802 000-€1.15m; $919 000-$1.31m).
Giles Roditi, president of the British Society of Cardiovascular Imaging, said, “It is beyond frustrating that we do not have the capacity to provide what should be a routine frontline test for everyone presenting with chest pain. Instead, in many hospitals it is easier for a runner with a dodgy knee to get a magnetic resonance scan than it is for a patient on the verge of a heart attack to get a CTCA.
“Deadly cases of heart disease are being missed because we can’t deliver these scans properly across the UK.”
- National Institute for Health and Care Excellence. Chest pain of recent onset: assessment and diagnosis (CG95). Nov 2016. https://www.nice.org.uk/guidance/cg95.
- S Mayor. Cardiac scan nearly halves future risk of heart attack in patients with chest pain, finds study. BMJ2018;362:k3656. 10.1136/bmj.k3656 30154171
- DE NewbyPD AdamsonC BerrySCOT-HEART Investigators. Coronary CT angiography and 5-year risk of myocardial infarction. N Engl J Med2018;379:924-33. 10.1056/NEJMoa1805971. 30145934
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