Appropriateness Criteria for Coronary Angiography in Angina: Reliability and Validity

19 August 2008 | Volume 149 Issue 4 | Pages 221-231

Background: Evaluated criteria for tailoring the decision to perform coronary angiography in specific clinical scenarios are lacking.

Objective: To determine the reliability and prognostic validity of patient-specific appropriateness criteria for coronary angiography among patients with suspected angina pectoris.

Design: Prospective observational study. Two independent panels of clinicians scored 2400 patient-specific indications for coronary angiography as inappropriate, uncertain, or appropriate. Using a simple computer algorithm, patients were matched to 1 of these indications.

Setting: 6 urban ambulatory care clinics in the United Kingdom.

Patients: 9356 consecutive patients with recent-onset chest pain in whom stable angina was suspected.

Measurements: Appropriateness ratings and clinical outcomes (coronary death and acute coronary syndrome events) over a median of 3 years of follow-up.

Results: 660 coronary deaths or acute coronary syndrome events occurred. Agreement between the 2 panels (reliability) on appropriateness category was moderate (weighted  = 0.58; P < 0.001). Use of subsequent angiography was strongly related to appropriateness category (P for linear trend <0.001) according to scores from either panel. Among patients judged as appropriate candidates for angiography, underuse was common (57% according to panel A and 71.3% according to panel B), and not undergoing coronary angiography was associated with higher coronary event rates than was undergoing the procedure. The hazard ratio after adjustment for age, sex, exercise electrocardiography result, and secondary prevention medication was similar according to panel A (2.78 [95% CI, 1.77 to 4.37]) and panel B (2.47 [CI, 1.72 to 3.55]).

Limitation: The study was too small to assess the relationship of angiography with coronary death and did not assess the reasons why patients did not receive angiography.

Conclusion: Appropriateness scores offer prognostically valid criteria for judging which specific patients might benefit from coronary angiography. Patient-specific appropriateness scores help pinpoint areas where judgments diverge and are a promising tool for making guidelines more effective.

Editors' Notes Context Can patient-specific appropriateness criteria developed by experts validly determine which patients with suspected angina should undergo coronary angiography? Contribution In this study, expert panels scored hundreds of patient-specific scenarios for coronary angiography as inappropriate, uncertain, or appropriate. Using a computer algorithm, researchers matched the devised appropriateness indications to 9356 clinic patients with recent-onset chest pain. They found that many patients judged as appropriate candidates did not undergo angiography and that this group had more subsequent coronary events than did patients who "appropriately" did have angiography. Implication Patient-specific appropriateness criteria are a promising tool for improving care of patients with suspected angina. —The Editors

 

Author and Article Information

From University College London Medical School, Barts and the London NHS Trust, Queen Mary's School of Medicine and Dentistry, and London School of Hygiene and Tropical Medicine, London, United Kingdom, and Greater Los Angeles Veterans Affairs Health Care System, Los Angeles, California.

Acknowledgment: The authors thank the members of the 2 panels: specialists Khalid Barakat (Wexham Park), Alison Calver (Southampton), Kieron Daly (Galway), Mary Heber (Telford), Rob Henderson (Nottingham), Diana Holdright (London), Bruce Keogh (Birmingham), Patrick Magee (London), Stuart Pringle (Dundee), Jeremy Sayer (Harlow), Jane Skinner (Newcastle), and Adam Timmis (London) and family physicians Naureen Bhatti (London), Peter Brindle (Bristol), Nick Dunn (Southampton), Martin Eccles (Newcastle), Tom Fahey (Dundee), Gene Feder (London), Richard McManus (Birmingham), Andrew Murphy (Galway), Neville Purssell (London), and Judy Shakespeare (Oxford).

Grant Support: By the United Kingdom Department of Health's Policy Research Programme and the NHS Research and Development Service Delivery and Organisation Programme. Dr. Hemingway was supported by a Public Health Career Scientist Award from the Department of Health.

Potential Financial Conflicts of Interest: None disclosed.

Reproducible Research Statement: Study protocol: Published elsewhere (11). Statistical code: Available from Dr. Chen (e-mail, ruoling.chen{at}ucl.ac.uk). Data set: Requests to use the data set for research should be directed to Dr. Timmis (e-mail, adamtimmis{at}mac.com).

Requests for Single Reprints: Harry Hemingway, MBBChir, University College London Medical School, 1-19 Torrington Place, London WC1E 6BT, United Kingdom; e-mail, h.hemingway{at}ucl.ac.uk.

Current Author Addresses: Drs. Hemingway, Chen, and Junghans: Department of Epidemiology and Public Health, University College London Medical School, 1-19 Torrington Place, London WC1E 6BT, United Kingdom.

Dr. Timmis: Department of Cardiology, The London Chest Hospital, Barts and the London NHS Trust, Bonner Road, London E2 9JX, United Kingdom.

Dr. Eldridge: Centre for Health Sciences, Barts and the London NHS Trust, Queen Mary's School of Medicine and Dentistry, Old Medical College Building, Turner Street, London E1 2AD, United Kingdom.

Dr. Black: Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom.

Dr. Shekelle: RAND Health, Evidence-based Practice Center, 1776 Main Street, Santa Monica, CA 90407.

Dr. Feder: Academic Unit of Primary Care, University of Bristol, 25 Belgrave Road London BS8 2AA, United Kingdom.

Author Contributions: Conception and design: H. Hemingway, C. Junghans, A. Timmis, N. Black, P. Shekelle, G. Feder.

Analysis and interpretation of the data: H. Hemingway, R. Chen, C. Junghans, A. Timmis, S. Eldridge, G. Feder.

Drafting of the article: H. Hemingway, S. Eldridge.

Critical revision of the article for important intellectual content: H. Hemingway, C. Junghans, A. Timmis, S. Eldridge, N. Black, P. Shekelle, G. Feder.

Final approval of the article: H. Hemingway, R. Chen, C. Junghans, A. Timmis, S. Eldridge, N. Black, P. Shekelle, G. Feder.

Provision of study materials or patients: A. Timmis.

Statistical expertise: R. Chen, S. Eldridge.

Obtaining of funding: H. Hemingway, C. Junghans.

Collection and assembly of data: H. Hemingway, S. Eldridge, A. Timmis.