Changes in coronary disease management decisions in real-world practice between 2015 and 2023: insights from the EVAREST/BSE-NSTEP observational study.

AIMS: To assess the real-world impact of updated clinical guidelines and literature on the management of patients undergoing stress echocardiography for the assessment of inducible ischaemia across a national health service. METHODS AND RESULTS: A total of 13 819 patients from 32 UK hospitals, referred for stress echocardiography between 2015 and 2023, were analysed across two phases: phase 1 (2015-2020) and phase 2 (2020-2023). Follow-up data for 1 year was available for 4920 participants through NHS Digital. Patients in phase 2 were younger and presented with a higher cardiovascular risk profile, although sex distribution remained similar across phases. There was an observed reduction in invasive angiography referrals within 1 year following a positive stress echocardiogram (P < 0.01), which appeared to be attributed to changes in the management of patients with moderate ischaemia (3-4 segments; P < 0.01). For those who did receive invasive assessment, there were no changes in intervention rate (P = 0.27), regardless of ischaemic burden. This trend was most evident in centres performing a higher volume of stress echocardiograms. CONCLUSION: Coronary disease management pathways have changed within the UK and fewer patients with moderate ischaemia are undergoing invasive coronary angiography. However, coronary intervention rates are unchanged, suggesting that stress echocardiography is being used to improve patient selection for invasive procedures while minimizing unnecessary referrals. Future work will assess if this reduction in angiography referrals is maintained long term, and if there are any effects on patient outcomes.