Should invasive coronary angiography be performed by non-cardiologist operators?

Br J Cardiol 2019;26(2)doi:10.5837/bjc.2019.013 Leave a comment
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First published online 11th April 2019

The concept of nurse-led angiography was first introduced in the UK just over two decades ago. This was in response to concerns raised following implementation of the Calman report.1 The Calman report recommended a structured training programme for cardiology registrars, thus, achieving clinical competence at a faster rate, with a view to filling anticipated consultant vacancies. However, it was presumed that this would negatively impact clinical service delivery. One particular concern was that there would be a reduced number of registrars available and able to perform coronary angiography. There was a fear that this shortfall would lead to reduced throughput within cardiology centres. Boulton et al. described a potential solution to this shortfall: the training of a clinical nurse specialist to perform coronary angiography.2 The aim was to teach the nurse-angiographer the technical skills to undertake coronary angiography, with a head-to-head comparison of procedural time, radiation exposure, and complication rate. The results were impressive with the nurse-angiographer demonstrating a numerical reduction in complication rate and fluoroscopy time. These results were similar to those of DeMots et al., who trained a physician assistant in Portland, Oregon to perform coronary angiography with a view to reducing the workload of trainee cardiologists.3

In this issue of the British Journal of Cardiology Yasin et al. describe the implementation of nurse-led angiography at Wycombe Hospital. Although not novel, the findings are certainly interesting. They performed a comparison of nurse-led coronary angiography with registrar-led angiography in an observational study of 200 patients. They examined procedural time, radiation exposure, contrast load and complication rates. Albeit small numbers, they demonstrated that nurse-led angiography was associated with a reduction in radiation and contrast load, concluding that a non-medical operator can be taught the technical skills required to perform coronary angiography safely. However, the observational nature of this study limits the conclusions that can be drawn. Although appropriate at an early level of training, the patients that underwent nurse-led angiography were a highly select ‘safe’ patient group, and, without baseline characteristics, it is not possible to determine if one arm of the study had more comorbidities than the other.

Future role?

This study by Yasin et al. suggests that there could be a role for experienced nurse operators in the future. However, since the inception of nurse-led angiography in the late 1980s, there have been considerable advancements in the technology and infrastructure within interventional cardiology centres. The number of centres now performing coronary angiography and percutaneous coronary interventions (PCI) has considerably increased, forming part of a larger group of strategic cardiac networks.4 Diagnostic coronary angiography, and the management of non-ST-elevation myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI) patients, are no longer limited to tertiary cardiac centres with an increased workforce.

The importance of performing coronary angiography to a high standard should not be underestimated. This includes safe vascular access and obtaining appropriate views. Coronary angiography remains the gold-standard test for determining the presence of coronary artery disease. However, to be truly diagnostic it has to be performed well, with acquisition of optimal views in order to fully elucidate the anatomy. There is strong evidence to now suggest that coronary angiography should no longer be performed in isolation. Findings of the R3F (Registre Français de la FFR) and recently published RIPCORD (Does Routine Pressure Wire Assessment Influence Management Strategy at Coronary Angiography for Diagnosis of Chest Pain) and POST-IT (Portuguese Study on the Evaluation of FFR Guided Treatment of Coronary Disease) studies of, collectively, more than 2,000 patients investigated the role of fractional flow reserve (FFR) at the time of diagnostic angiography.5-7 Importantly, in all three studies, the significance of coronary artery disease was reclassified in approximately one-third of patients using FFR compared with coronary angiography alone. In other words, visual assessment of coronary disease was found to be incorrect in one-third of cases. This raises the question of whether or not all coronary angiography should be performed by interventional cardiologists, and, anecdotally, there are cases in which coronary angiography has to be repeated, exposing patients to further radiation and a further procedure. Furthermore, there are certain situations when bail-out PCI is necessary, although rare, these include catheter-induced dissection and NSTEMI with unstable coronary appearances, and it is important in these situations to be able to perform angioplasty promptly and safely. Therefore, the exact role for nurse-led angiography remains unclear, and further work is needed to elucidate which scenarios would be best served by this technique.

Conflicts of interest

None declared.

Editor’s note

There is no question that a nurse can do diagnostic coronary angiography as well as a junior doctor; the problem today is, now we have CT Fractional Flow Reserve (CT FFR), the need for diagnostic angiography is rapidly declining. If, therefore, nurses perform the majority of coronary angiograms, there will not be an opportunity to train doctors so that they can ultimately take on the complex cases or percutaneous coronary intervention (PCI). KF

The study by Yasin et al. to which this editorial refers can be found here.

References

1. Calman K. Hospital doctors: training for the future. BJOG 1995;102:354–6. https://doi.org/10.1111/j.1471-0528.1995.tb11283.x

2. Boulton BD, Bashir Y, Ormerod OJM, Gribbin B, Forfar JC. Cardiac catheterisation performed by a clinical nurse specialist. Heart 1997;78:194–7. https://doi.org/10.1136/hrt.78.2.194

3. DeMots H, Coombs B, Murphy E, Palac R. Coronary arteriography performed by a physician assistant. Am J Cardiol 1987;60:784–7. https://doi.org/10.1016/0002-9149(87)91023-X

4. Ludman P, Bradley A for NICOR, BCIS and HQIP. National audit of percutaneous coronary interventions. Annual public report. 1 January 2015 – 31 December 2015. London: NICOR, 2017. Available from: https://www.hqip.org.uk/wp-content/uploads/2018/02/national-audit-of-percutaneous-coronary-intervention-annual-public-report.pdf

5. Van Belle E, Rioufol G, Pouillot C et al. Outcome impact of coronary revascularization strategy reclassification with fractional flow reserve at time of diagnostic angiography: insights from a large French multicenter fractional flow reserve registry. Circulation 2014;129:173–85. https://doi.org/10.1161/CIRCULATIONAHA.113.006646

6. Curzen N, Rana O, Nicholas Z et al. Does routine pressure wire assessment influence management strategy at coronary angiography for diagnosis of chest pain? The RIPCORD study. Circ Cardiovasc Interv 2014;7:248–55. https://doi.org/10.1161/CIRCINTERVENTIONS.113.000978

7. Baptista SB, Raposo L, Santos L et al. Impact of routine fractional flow reserve evaluation during coronary angiography on management strategy and clinical outcome. Circ Cardiovasc Interv 2016;9:e003288. https://doi.org/10.1161/CIRCINTERVENTIONS.115.003288

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