1. Cardiac Diagnostic Imaging Services Dr Andrew Wood UHW Cardiff 14 th July 2010

2. Cardiac Diagnostic Imaging ► Chest radiograph ► Echocardiography (cardiac ultrasound)  TOE  Stress echo ► Cardiac catheterisation  Coronary angiography ► Nuclear cardiology  Stress myocardial perfusion 1990 2010

3. Cardiac Diagnostic Imaging 2010 ► Chest radiograph ► Echocardiography (cardiac ultrasound)  TOE  Stress echo ► Cardiac catheterisation  Coronary angiography ► Nuclear cardiology  Stress myocardial perfusion ► Cardiac CT ► Cardiac MR

4. Cardiac CT ► Primary role in replacing coronary angiography in selected patients ► Secondary role in imaging other cardiac pathology

5. Cardiac CT ► Primary role in replacing coronary angiography in selected patients ► Secondary role in imaging other cardiac pathology

6. Coronary artery disease ► Coronary heart disease is a leading cause of death in the United Kingdom, and particularly in Wales ► >8,000 deaths/year in Wales from CHD

7. Coronary angiography ► Definitive anatomical test to diagnose coronary artery disease ► Recognised target - 5000 invasive coronary angiograms per million population in Wales

8. Coronary Angiography ► Invasive ► Expensive ► Patient mortality  1 in 1,000 ► Patient Morbidity  Stroke  Heart attack  Arterial trauma  Bruising

9. Coronary Angiography ► Invasive  Arterial puncture  Catheter manipulated into coronary arteries ► Expensive  Hardware ► Cath Lab ► Patient monitoring  Staff ► Cardiologist, nursing, technician, radiographer, support  Facilities ► Observation area – day case facility, staff etc ► Patient mortality ► Patient Morbidity

10. CT coronary Angiography ► Non - Invasive  Venous puncture ► Less Expensive  Hardware ► CT ► ECG & BP monitor  Staff ► Radiologist, radiographer, support  Facilities ► 30 minute post procedure observation ► Patient mortality ► Patient Morbidity

11. CT coronary Angiography ► Invasive ► Expensive ► Patient mortality  1 in 250,000 ► Patient Morbidity  Contrast reactions  Extravasation at venous injection site  hypotension

12. CT coronary Angiography ► Target  Patient selection ► Low pre test probability  Replace 20% of invasive coronary angiography

13. CT coronary Angiography ► Target  Patient selection  Replace 20% of invasive coronary angiography ► Advantages  Cost saving  Improved patient experience  Decreased patient morbidity & mortality  Additional incidental diagnosis

14. CT coronary Angiography ► Advantages  Cost saving ► SE Wales target 7,000 angios/year ► 20% to CT = 1,400 ► 1,400 x £1,000 per patient = £1.4x10 6  Improved patient experience  Decreased patient morbidity & mortality  Additional incidental diagnosis

15. CT coronary Angiography ► Investment  CT scanner time ► 1400 cases/year ► 175 CT sessions/year ► 4 dedicated cardiac CT sessions per week  Radiographic & support staff ► Pro rata  Radiologist/cardiologist ► 1 new WTE  Education

16. Cardiac MR ► Cardiac MR  Ischaemic heart disease  Cardiomyopathy  Congenital heart disease  Aorta pathology  Valve disease  Pericardial disease

17. Cardiac MR ► Cardiac MR  Ischaemic heart disease ► Differentiate irreversible from reversible ischaemia ► Plan expensive intervention (PCI,CABG) ► More efficient use of PCI & CABG

18. Cardiac MR ► Cardiac MR  Cardiomyopathy ► Improved diagnosis ► Improved prognostic information ► Improved utilisation of treatment option  ICD  Cardiac resynchronisation

19. Cardiac MR ► Cardiac MR  Congenital heart disease ► Echo less useful in older population ► Accurate anatomical diagnosis ► Prognostic information ► Timing of complex intervention  Redo open heart surgery  Percutaneous valve replacement

20. Cardiac MR ► Investment  MR scanner ► Increase in capacity ► Target - 1 dedicated cardiac MR scanner for SE Wales  Radiographic staff ► Pro rata  Radiology ► 1 dedicated cardiac radiologist ► 1 cardiac radiologist with other subspecialty ► 1 cardiologist with an interest in imaging

21. Overall ► Cardiac CT & MR are now essential components of tertiary and secondary cardiology ► Wales has fallen behind in provision of both these services due to the commissioning disconnect between ‘front line’ clinical services and support services

22. ► Major investment is required to catch up  CT session  MR scanner  Radiographic & support staff  Radiologist/cardiologist

24. The costs - CT ► Hardware  CT – 4 sessions ► Capital£250K ÷ 7 ► Revenue£280K ► Radiographic & support ► 1wte radiographer£40K ► 1wte RDA£25K ► Consultant ► 1wte£100K

25. The costs - MR ► Hardware  CT – 4 sessions ► Capital£1,000K ÷ 7 ► Revenue£1,000K ► Radiographic & support ► 3wte radiographer£120K ► 1wte RDA£25K ► Consultant ► 2wte£200K