Impact case study database

CAD is a leading cause of death and disability worldwide, and the leading single cause of mortality in Europe, responsible for 862,000 deaths a year (19% of all deaths) among men and 877,000 deaths (20%) among women. In the UK, there are an estimated 1.98 million people suffering with symptoms of angina, and CAD costs the UK economy GBP9 billion a year. Our CE-MARC trial provided the largest real-world evidence of the diagnostic accuracy of CMR, its prognostic ability and cost effectiveness, showing superiority over the current NHS reference standard. As a result, CE-MARC provided the evidence base leading to the first inclusion of CMR into international clinical guidelines for chest pain investigation (European & US). This contributed to CMR for stable CAD detection being rapidly introduced across the NHS.

Inclusion of CMR for the first time in international guidelines

The CE-MARC trial results underpin the high level of evidence (Class 1) and are cited to support the use of CMR for stable chest pain investigation in the European and US clinical guidelines. US guidelines on appropriate use criteria for the detection and risk assessment of stable CAD cite the CE-MARC trial as evidence supporting the utility and accuracy of stress CMR [ A]. European guidelines on the management of stable CAD cite the CE-MARC trial as evidence for the diagnostic accuracy of CMR perfusion imaging compared with MPS [ B]. Additionally, Greenwood is on the writing committee for the 2021 AHA/ACC/ASE/ASNC/ CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain. Notably, this writing group is normally comprised of American experts. Greenwood was invited to be a part of this group in view of “professional standing, expertise, and track record of managing patients with chest pain, which was superior to any other colleagues in the US and indeed globally” [ C]. The results of CE-MARC and CE-MARC 2 have been cited as underpinning evidence to support the recommendation for stress CMR to be used as an effective frontline investigation in the diagnosis of stable chest pain.

The CEO of the Society for Cardiovascular Magnetic Resonance has acknowledged the “ground-breaking” CE-MARC and CE-MARC-2 trials, which have significantly impacted the practice of cardiology globally, saving money to healthcare systems, reducing patients’ risk and improving patients’ quality of life on clinical cardiology practice and improving patients’ management using CMR globally [ C]. The significant contribution the trials have had on international guidelines for the management of chest pain has also been emphasised:

“Stress CMR is now recommended in Class I (which means there is evidence and/or general agreement that a given treatment or procedure is beneficial, useful, effective) with the level of evidence A (which means the data is supported by randomised trials). Class IA is the highest level of recommendation and evidence in ESC/AHA/ACC guideline documents. Guidelines from leading scientific societies such as the European Society of Cardiology are the reference documents that cardiologists in Europe and worldwide use to guide clinical practice” [ C].

Cost-effectiveness of CMR over other diagnostic strategies

The availability of a more accurate diagnostic test reduces the need for down-stream investigations, including expensive invasive coronary angiography. Health economic analysis of CE-MARC showed that CMR was more cost effective for the NHS than MPS-SPECT (which was the prior clinical reference standard). The results from this economic evaluation suggest that CMR should be considered as part of a diagnostic strategy for the identification of patients with CAD suitable for revascularisation.

Economic evaluation of CE-MARC 2 to assess the cost-effectiveness of CMR, MPS and NICE guidelines showed CMR had the highest estimated quality-adjusted life year (QALY) gain overall (2.21 (95% credible interval 2.15, 2.26) compared with 2.07 (1.92, 2.20) for NICE and 2.11 (2.01, 2.22) for MPS) and incurred comparable costs (overall GBP1625 (GBP1431, GBP1824) compared with GBP1753 (GBP1473, GBP2032) for NICE and GBP1768 (GBP1572, GBP1989) for MPS) [ D]. Overall, CMR was the cost-effective strategy, being the dominant strategy (more effective, less costly) with incremental net health benefits per patient of 0.146 QALYs (−0.18, 0.406) compared with NICE guidelines at a cost-effectiveness threshold of GBP15 000 per QALY (93% probability of cost-effectiveness).

Data from CE-MARC and its economic model have also been used internationally to show CMR cost-effectiveness, e.g. in Switzerland [ E] and Australia [ F].

Dramatic uptake in stress perfusion CMR services across UK

Results from the CE-MARC and CE-MARC 2 trials showing the high diagnostic accuracy and cost effectiveness of CMR have directly impacted on NHS practice. This is evidenced by the dramatic uptake in stress perfusion CMR services across the UK and also uptake in Europe/globally.

In 2008, survey data revealed 20,597 CMR scans were performed in the UK. This compares to 114,967 scans in 2018, representing a remarkable 5-fold increase over 10-years. Additionally, 100,386 scans were performed in 2017, representing a single year increase of 14.7%. In total, ~24% of all UK CMR was for CAD [ G]. When focusing on a single Trust, Leeds Teaching Hospitals confirmed that the number of CMR scans has dramatically increased by 135% in the last 10 years (1001 scans in 2010 compared to 2348 in 2020), while numbers of MPS activity have reduced in support of a shift in referrals based on the CE-MARC and CE-MARC-2 trials (1715 scans for the 2014-15 financial year, compared with 1021 for the 2019-20 financial year) [ H].

The European CMR Registry (EuroCMR) with over 37,000 patients from 57 European centres has demonstrated the impact of CMR on clinical diagnosis and management in Europe. The US multi-centre SPINS registry has shown that CMR in stable chest pain syndromes was a highly effective prognostic test associated with low healthcare costs spent on downstream cardiac testing [ I].