Gamechangers

Chest pain is a common presenting symptom. Identifying patients with underlying coronary artery disease (CAD) is challenging 1. Across Northern Ireland, Exercise Stress Testing (EST) is the commonest first line investigation at chest pain clinics. EST has a 45-50% sensitivity for predicting CAD. 1 One third of patients diagnosed with non-cardiac chest pain develop ACS or die from IHD within 5 years. 1 NICE guidelines support Cardiac CT in assessing low-intermediate risk patients. The two key components are CT coronary angiography (CTCA) and Calcium Scoring. CTCA has a high negative predictive value for excluding CAD making it a potential 'gatekeeper' to invasive angiography. It is proposed as the best non-invasive investigation in the assessment of angina given its high sensitivity (89%) and specificity (96%). 1 Calcium scoring acts as a surrogate marker for atherosclerotic disease and functions as a risk stratification tool. The presence of any detectable calcium on CT is associated with a fourfold increase in coronary events over 3 years. 2 An emerging use of cardiac CT is incorporating functional assessment of CAD by fractional flow reserve (FFR) to help diagnose ischaemia. CTFFR can provide high diagnostic accuracy for the diagnosis of haemodynamically significant CAD with invasive FFR as the reference standard. 3 Improved technology has helped reduce some concerns with implementing Cardiac CT. Multi-slice scanners can reduce the imaging field and have less heart rate dependency, helping reduce radiation dose. This also enables imaging of patients previously too challenging e.g. atrial fibrillation. Compelling evidence exists for incorporating cardiac CT into chest pain pathways. It can help reduce diagnostic uncertainty and guide the use of invasive angiography, improving outcomes for patients. 1. Moss AJ, Newby DE. CT coronary angiographic evaluation of suspected anginal chest pain. 3. Nørgaard BL et al. Diagnostic performance of noninvasive fractional flow reserve derived from coronary computed tomography angiography in suspected coronary artery disease: the NXT trial (Analysis of Coronary Blood Flow Using CT Angiography: Next Steps). Since 1980 transvenous implantable cardioverter defibrillators (TV-ICDs) have been the cornerstone of sudden cardiac death prevention. They are, however, associated with venous stenosis, thrombosis, endocarditis and lead failure rates of up to 20% at 10 years. Extraction of infected or failed TV-ICD leads is highly challenging 1. A significant proportion of these complications could be avoided with use of a new subcutaneous-ICD (S-ICD), which comprises a lead tunneled in the subcutaneous tissue along the left sternal edge …