The impact and challenges of implementing CTCA according to the 2019 ESC guidelines on chronic coronary syndromes: a survey and projection of CTCA services in the Netherlands

Abstract

Background: The 2019 ESC-guidelines on chronic coronary syndromes (ESC-CCS) recommend computed tomographic coronary angiography (CTCA) or non-invasive functional imaging instead of exercise ECG as initial test to diagnose obstructive coronary artery disease. Since impact and challenges of these guidelines are unknown, we studied the current utilisation of CTCA-services, status of CTCA-protocols and modeled the expected impact of these guidelines in the Netherlands.

Methods and results: A survey on current practice and CTCA utilisation was disseminated to every Dutch hospital organisation providing outpatient cardiology care and modeled the required CTCA capacity for implementation of the ESC guideline, based on these national figures and expert consensus. Survey response rate was 100% (68/68 hospital organisations). In 2019, 63 hospital organisations provided CTCA-services (93%), CTCA was performed on 99 CTCA-capable CT-scanners, and 37,283 CTCA-examinations were performed. Between the hospital organisations, we found substantial variation considering CTCA indications, CTCA equipment and acquisition and reporting standards. To fully implement the new ESC guideline, our model suggests that 70,000 additional CTCA-examinations would have to be performed in the Netherlands.

Conclusions: Despite high national CTCA-services coverage in the Netherlands, a substantial increase in CTCA capacity is expected to be able to implement the 2019 ESC-CCS recommendations on the use of CTCA. Furthermore, the results of this survey highlight the importance to address variations in image acquisition and to standardise the interpretation and reporting of CTCA, as well as to establish interdisciplinary collaboration and organisational alignment.

Keywords: Computed Tomography Angiography; Coronary artery disease; Guidelines.

Fig. 1

(a) The number of hospitals that perform CTCA, (b) the number of CTCA-capable CT-scanners per million inhabitants, (c) the number of CTCA-examinations per million inhabitants, (d) the number of CTCA-examinations per CT-scanner. The black coloured areas represent densely populated urban areas

Fig. 2

The number of CTCA-examinations per hospital type. The number of CTCA scans is plotted on the y-axis per hospital, as coloured boxes. The stacked boxes correspond with the cumulative number of CTCA-examinations per province (x-axis). The provinces are grouped, according to the number of inhabitants: < 1 million inhabitants (left frame), 1–2 million inhabitants (middle frame) and > 2 million inhabitants (right frame). The colour of the boxes correspond with the type of hospital, as listed in the legend

Fig. 3

First row Pie charts showing the number of hospitals that perform CTCA for the indications: Chest pain, non-coronary cardiac surgery, ventricular tachycardia (VT) or heart failure and known CAD. Second row Differentiation in hospitals type of the hospitals that perform CTCA for the corresponding indication. The number of hospitals is shown in the pie slices

Fig. 4

Downstream diagnostic tests after CTCA with significant stenosis, differentiated between hospital types. The number of hospitals is shown in the pie slices. * There was one hospital that only performed non-invasive diagnostics, which was a non-PCI centre

Fig. 5

Absolute number increase in annual CTCA scans per province for an implementation rate of the current ESC guidelines of 50% (a), 75% (b) and 100% (c)