NICE guidelines for the management of patients with acute chest pain: Difference between revisions

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{{Chest pain}}
{{Chest pain}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}}; [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com]
{{CMG}}; '''Associate Editor(s)-In-Chief:''' {{Sara.Zand}} {{CZ}}; [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com]


==Overview==
==Overview==
The American College of Cardiology, American Heart Association,and National Institute for Health and Clinical Excellence (NICE) guidelines recommends performance of ECG for all patients with cardiac chest pain. Additionally, chest x-rays in patients with suspected [[congestive heart failure]], [[aortic dissection]], [[aortic aneurysm]], [[valvular heart disease]], pericardial disease. However, the guidelines recommend exercise testing in low and intermediate risk patients only after they have been screened for high risk features and other indications for hospital admission.
In the 2016 update of the stable [[chest pain]] guideline, [[National Institute for Health and Clinical Excellence]] ([[NICE]]) has dramatically changed its approach to new-onset stable [[chest pain]] aiming to find a more cost-effective strategy including NO use of pretest probability risk scores or NO use of functional tests, such as [[stress echocardiography]], as a first-line investigation. The suggestion is to use CT coronary angiography in [[patients] with typical or atypical [[chest pain]]. In addition, there is no recommendation for any diagnostic testing if [[chest pain]] is non-anginal. Also, [[perfusion imaging]] is offered in the setting of uncertainty about the functional significance of [[coronary]] lesions. However, the recommendation of the [[European Society of Cardiology]] ([[ESC]]—2013) is functional tests as the initial investigation.


==NICE Guidelines for the Management of Patients with Acute Chest Pain <ref name="pmid30533431">{{cite journal |vauthors=Carrabba N, Migliorini A, Pradella S, Acquafresca M, Guglielmo M, Baggiano A, Moscogiuri G, Valenti R |title=Old and New NICE Guidelines for the Evaluation of New Onset Stable Chest Pain: A Real World Perspective |journal=Biomed Res Int |volume=2018 |issue= |pages=3762305 |date=2018 |pmid=30533431 |pmc=6250018 |doi=10.1155/2018/3762305 |url=}}</ref>==
==NICE Guidelines for the Management of Patients with Acute Chest Pain <ref name="pmid30533431">{{cite journal |vauthors=Carrabba N, Migliorini A, Pradella S, Acquafresca M, Guglielmo M, Baggiano A, Moscogiuri G, Valenti R |title=Old and New NICE Guidelines for the Evaluation of New Onset Stable Chest Pain: A Real World Perspective |journal=Biomed Res Int |volume=2018 |issue= |pages=3762305 |date=2018 |pmid=30533431 |pmc=6250018 |doi=10.1155/2018/3762305 |url=}}</ref>==
{{cquote|
===Initial Assessment and Referral to Hospital===


* Check immediately whether people currently have chest pain. If they are pain free, check when their last episode of pain was, particularly if they have had pain in the last 12 hours.
::* Symptoms suggestive od [[acute coronary syndromes]]:
* Determine whether the chest pain may be cardiac and therefore whether this guideline is relevant, by considering:
*Pain in the [[chest]] and/or other areas (for example, the [[arms]], [[back]] or [[jaw]]) lasting longer than 15 minutes ·
** The history of the chest pain
*[[Chest pain]] associated with [[nausea]] and [[vomiting]], marked [[sweating]], [[breathlessness]], or particularly a combination of these ·
** The presence of cardiovascular risk factors
* [[Chest pain]] associated with [[hemodynamic]] instability ·
** History of ischaemic heart disease and any previous treatment
* New onset [[chest pain]], or abrupt deterioration in previously stable angina, with recurrent [[chest pain]] occurring frequently and with little or no exertion, and with episodes often lasting longer than 15 minutes
** Previous investigations for chest pain


* Initially assess people for any of the following symptoms, which may indicate an ACS:
::* If the [[patient]] is currently pain-free, but had [[chest pain]] in the last 12 hours, and resting 12-lead ECG is abnormal or not available or develops further [[chest pain]] after recent (confirmed or suspected) [[ACS]], evaluation about [[ACS]] is warranted.
** Pain in the chest and/or other areas (for example, the arms, back or jaw) lasting longer than 15 minutes
** Chest pain associated with nausea and vomiting, marked sweating, breathlessness, or particularly a combination of these
** Chest pain associated with haemodynamic instability
** New onset chest pain or abrupt deterioration in previously stable angina, with recurrent chest pain occurring frequently and with little or no exertion, and with episodes often lasting longer than 15 minutes
** Do not use people's response to glyceryl trinitrate (GTN) to make a diagnosis.
* Do not assess symptoms of an ACS differently in men and women. Not all people with an ACS present with central chest pain as the predominant feature.
** Do not assess symptoms of an ACS differently in ethnic groups. There are no major differences in symptoms of an ACS among different ethnic groups.
* Refer people to hospital as an emergency if an ACS is suspected and:
** They currently have chest pain or
** They are currently pain free, but had chest pain in the last 12 hours, and a resting 12-lead electrocardiography (ECG) is abnormal or not available.


* If an ACS is suspected and there are no reasons for emergency referral, refer people for urgent same-day assessment if:
::* Management of [[ACS]]:
** They had chest pain in the last 12 hours, but are now pain free with a normal resting 12-lead ECG or
* Transferring the [[patient]] to [[hospital]] immediately 
** The last episode of pain was 12–72 hours ago.
*Taking a resting 12-lead [[ECG]] ·
* Managing pain with [[TNG]] and/or an [[opioid]]
*Giving a single dose of 300 mg [[aspirin]] unless the person is [[allergic]], and other neccessary therapeutic interventions
* Checking  [[oxygen saturation]] and administer [[oxygen]] if appropriate
* Monitoring the [[patient]]


* Refer people for assessment in hospital if an ACS is suspected and:
::* Assessment of [[patients]] with suspected [[ACS]] in the hospital:
** The pain has resolved and
*[[ Physical examination]] to determine:
** There are signs of complications such as pulmonary edema
* [[Hemodynamic]] status
* Use clinical judgment to decide whether referral should be as an emergency or urgent same-day assessment.
* Signs of complications, including [[pulmonary oedema]], [[cardiogenic shock]]
** If a recent ACS is suspected in people whose last episode of chest pain was more than 72 hours ago and who have no complications such as pulmonary oedema:
* Signs of non-[[coronary]] causes of acute [[chest pain]], such as [[aortic dissection]]
*** Carry out a detailed clinical assessment
* Taking a detailed clinical [[history]] unless a [[STEMI]] is confirmed from the resting 12-lead [[ECG]] (regional ST-segment elevation or presumed new [[LBBB]])
*** Confirm the diagnosis by resting 12-lead ECG and blood troponin level
:* The characteristics of the [[pain]]
*** Take into account the length of time since the suspected ACS when interpreting the troponin level.
:* Other associated symptoms
*** Use clinical judgment to decide whether referral is necessary and how urgent this should be.
:* Any [[history]] of [[cardiovascular disease]]
*** Refer people to hospital as an emergency if they have a recent (confirmed or suspected) ACS and develop further chest pain.
*** When an ACS is suspected, start management immediately in the order appropriate to the circumstances and take a resting 12-lead ECG. Take the ECG as soon as possible, but do not delay transfer to hospital.
* If an ACS is not suspected, consider other causes of the chest pain, some of which may be life-threatening.


===Resting 12-Lead ECG===
* Routinely administration of [[oxygen]] is not recommended, but monitoring  [[oxygen saturation]] and [[pulse oximetry]] as soon as possible, ideally, before [[hospital admission]] is recommended.  
* Take a resting 12-lead ECG as soon as possible.
* Indications for supplemental [[oxygen]]:
* When people are referred, send the results to hospital before they arrive if possible.
* [[Oxygen saturation]] ([[SpO2]]) of less than 94% who are not at risk of [[hypercapnic respiratory failure]], aiming for SpO2 of 94–98%
* Recording and sending the ECG should not delay transfer to hospital.
* [[Chronic obstructive pulmonary disease]] who are at risk of [[hypercapnic respiratory failure]], to achieve a target SpO2 of 88–92% until [[blood gas analysis]] is available.  
* Follow local protocols for people with a resting 12-lead ECG showing regional ST-segment elevation or presumed new left bundle branch block (LBBB) consistent with an acute STEMI until a firm diagnosis is made. Continue to monitor.
::* [[Patients]] with acute [[chest pain]] should be monitored for:
* Follow Unstable angina and NSTEMI for people with a resting 12-lead ECG showing regional ST-segment depression or deep T wave inversion suggestive of a NSTEMI or unstable angina until a firm diagnosis is made. Continue to monitor.
*Exacerbations of [[pain]] and/or other [[symptoms]]
* Even in the absence of ST-segment changes, have an increased suspicion of an ACS if there are other changes in the resting 12-lead ECG, specifically Q waves and T wave changes. Consider following Unstable angina and NSTEMI if these conditions are likely. Continue to monitor.
* [[Pulse]] and [[blood pressure]]
* Do not exclude an ACS when people have a normal resting 12-lead ECG.
* [[Heart rhythm ]]
* If a diagnosis of ACS is in doubt, consider:
* [[Oxygen saturation]] by [[pulse oximetry ]]
** Taking serial resting 12-lead ECGs
· Repeated resting 12-lead [[ECGs]]
** Reviewing previous resting 12-lead ECGs
· Checking pain relief
** Recording additional ECG leads
* Use clinical judgment to decide how often this should be done. Note that the results may not be conclusive.
* Obtain a review of resting 12-lead ECGs by a healthcare professional qualified to interpret them as well as taking into account automated interpretation.
* If clinical assessment and a resting 12-lead ECG make a diagnosis of ACS less likely, consider other acute conditions. First consider those that are life threatening such as pulmonary embolism, aortic dissection or pneumonia. Continue to monitor.


===Immediate Management of a Suspected Acute Coronary Syndrome===
::*Use of biochemical markers for diagnosis of an [[acute coronary syndrome]]:
* Management of ACS should start as soon as it is suspected, but should not delay transfer to hospital. The recommendations in this section should be carried out in the order appropriate to the circumstances.
*Use of high-sensitivity [[troponin]] tests is not recommended, if [[ACS]] is not suspected
* Offer pain relief as soon as possible. This may be achieved with glyceryl trinitrate (GTN) (sublingual or buccal), but offer intravenous opioids such as morphine, particularly if an acute myocardial infarction (MI) is suspected.
*For [[patients]] at high or moderate risk of [[MI]] (as indicated by a validated tool), performing high sensitivity [[troponin]] tests is reasonable.
* Offer people a single loading dose of 300 mg aspirin as soon as possible unless there is clear evidence that they are allergic to it.
*For [[patients]] at low risk of [[MI]] :
* If aspirin is given before arrival at hospital, send a written record that it has been given with the person. Only offer other antiplatelet agents in hospital. Follow appropriate guidance.
* Performing a second high-sensitivity [[troponin]] test
* Do not routinely administer oxygen, but monitor oxygen saturation using pulse oximetry as soon as possible, ideally before hospital admission. Only offer supplemental oxygen to:
* Considering a single high-sensitivity [[troponin]] test only at presentation to rule out [[NSTEMI ]], if the first [[troponin]] test is below the lower limit of detection (negative).
** People with oxygen saturation (SpO<sub>2</sub>) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO<sub>2</sub> of 94–98%
*A detectable [[troponin]] on the first high-sensitivity test does not necessary for [[patients]] with confirmed [[MI]].
** People with chronic obstructive pulmonary disease who are at risk of hypercapnic respiratory failure, to achieve a target SpO<sub>2</sub> of 88–92% until blood gas analysis is available.
*For diagnose of [[ACS]] use of biochemical markers such as [[natriuretic peptides]] and high-sensitivity C-reactive protein  are not recommended.
* Monitor people with acute chest pain, using clinical judgment to decide how often this should be done, until a firm diagnosis is made. This should include:
.
** Exacerbations of pain and/or other symptoms
* Checking biochemical markers of [[myocardial ischemia]] (such as ischemia-modified albumin) as opposed to markers of [[necrosis]] is not recommended  in [[patients]] with acute [[chest pain]].
** Pulse and blood pressure
:* Factors should be considered for interpreting high-sensitivity [[troponin]]:
** Heart rhythm
* the clinical presentation
** Oxygen saturation by pulse oximetry
* The time from onset of [[symptoms]]
** Repeated resting 12-lead ECGs and
* The resting 12-lead ECG findings
** Checking pain relief is effective
* The pre-test probability of [[NSTEMI]]
* Manage other therapeutic interventions using appropriate guidance.
* The length of time since the suspected [[ACS]]
* The probability of chronically elevated [[troponin]] levels in some [[patients]]
* That 99th percentile threshold for [[troponin]] I and T may differ between [[sexes]].


===Assessment in Hospital for People with a Suspected Acute Coronary Syndrome===
::*Universal definition of [[myocardial infarction]]:
* Take a resting 12-lead ECG and a blood sample for troponin I or T measurement on arrival in hospital.
*Detection of rising and/or falling of [[cardiac]] biomarkers values (preferably cardiac [[troponin]] ([[cTn]]) with at least one value above the 99th percentile of the upper reference limit and at least one of the following:  
* Carry out a physical examination to determine:
* [[Symptoms]] of [[ischaemia]]
** Haemodynamic status
* New or presumed new significant ST-segment-T wave(ST-T) changes or new [[left bundle branch block]] ([[LBBB]])  
** Signs of complications, for example pulmonary edema
* Development of pathological [[Q waves]] in the [[ECG]]
** Cardiogenic shock and
*Imaging evidence of new loss of [[viable myocardium ]] or new [[regional wall motion abnormality]]
** Signs of non-coronary causes of acute chest pain, such as aortic dissection
*Identification of an [[intracoronary thrombus]] by [[angiography]]
* Take a detailed clinical history unless a STEMI is confirmed from the resting 12-lead ECG (that is, regional ST-segment elevation or presumed new left bundle branch block [LBBB]). Record:
** The characteristics of the pain
** Other associated symptoms
** Any history of cardiovascular disease
** Any cardiovascular risk factors and
** Details of previous investigations or treatments for similar symptoms of chest pain.
===Use of Biochemical Markers for Diagnosis of an Acute Coronary Syndrome===
* Take a blood sample for troponin I or T measurement on initial assessment in hospital. These are the preferred biochemical markers to diagnose acute MI.
* Take a second blood sample for troponin I or T measurement 10–12 hours after the onset of symptoms.
* Do not use biochemical markers such as natriuretic peptides and high sensitivity C-reactive protein to diagnose an ACS.
* Do not use biochemical markers of myocardial ischaemia (such as ischaemia-modified albumin) as opposed to markers of necrosis when assessing people with acute chest pain.
* Take into account the clinical presentation, the time from onset of symptoms and the resting 12-lead ECG findings when interpreting troponin measurements.


===Making a Diagnosis===
* When a raised [[troponin]] level is detected in [[patients]] suspected [[ACS]], other causes for raised troponin should be excluded (for example, [[myocarditis]],[[ aortic dissection]] or [[pulmonary embolism]])  
* When diagnosing MI, use the universal definition of myocardial infarction. This is the detection of rise and/or fall of cardiac biomarkers (preferably troponin) with at least one value above the 99th percentile of the upper reference limit, together with evidence of myocardial ischaemia with at least one of the following:
* In [[patients]] with [[chest pain]] without raised [[troponin]] levels and no resting 12-lead [[ECG]] changes, determine whether their [[chest pain ]] is likely to be [[cardiac]].  
** Symptoms of ischaemia
*If[[ myocardial ischemia]] is suspected, follow the recommendations on stable [[chest pain]].
** ECG changes indicative of new ischaemia (new ST-T changes or new LBBB)
*  [[Clinical]] judgment is important to decide on the timing of any further diagnostic investigations.
** Development of pathological Q wave changes in the ECG
* Routinely use of non-invasive imaging or [[exercise ECG]] in the initial assessment of acute [[cardiac chest pain]] is not recommended.
** Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality.
* [[Chest computed tomography]] (CT) is recommended to rule out other diagnoses such as [[pulmonary embolism]] or [[aortic dissection]], not to diagnose [[ACS]].
* The clinical classification of MI includes:
*[[ Chest X-ray]] is helpful to exclude complications of [[ACS]] such as [[pulmonary oedema]], or other diagnoses such as [[pneumothorax]] or [[pneumonia]].
** Type 1: spontaneous MI related to ischaemia due to a primary coronary event such as plaque erosion and/or rupture, fissuring or dissection.
*If an [[ACS]] has been excluded but [[patients]] have risk factors for [[cardiovascular]] disease, following appropriate guidance is recommended, for example, the NICE guidelines on [[cardiovascular disease]] and [[hypertension]].
** Type 2: MI secondary to ischaemia due to either increased oxygen demand or decreased supply, such as coronary spasm, coronary embolism, anaemia, arrhythmias, hypertension, or hypotension.
* When a raised troponin level is detected in people with a suspected ACS, reassess to exclude other causes for raised troponin (for example, myocarditis, aortic dissection or pulmonary embolism) before confirming the diagnosis of ACS.
* When a raised troponin level is detected in people with a suspected ACS, follow the appropriate guidance until a firm diagnosis is made. Continue to monitor.
* When a diagnosis of ACS is confirmed, follow the appropriate guidance.
* Reassess people with chest pain without raised troponin levels (determined from appropriately timed samples) and no acute resting 12-lead ECG changes to determine whether their chest pain is likely to be cardiac. If myocardial ischaemia is suspected, follow the recommendations on stable chest pain in this guideline. Use clinical judgment to decide on the timing of any further diagnostic investigations.
* Consider a chest x-ray to help exclude complications of ACS such as pulmonary edema, or other diagnoses such as pneumothorax or pneumonia.
* Only consider early chest computed tomography (CT) to rule out other diagnoses such as pulmonary embolism or aortic dissection, not to diagnose ACS.
* If an ACS has been excluded at any point in the care pathway, but people have risk factors for cardiovascular disease, follow the appropriate guidance, for example lipid modification, hypertension.
}}


==References==
==References==

Latest revision as of 18:18, 14 January 2022

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Sara Zand, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3]; Priyamvada Singh, M.B.B.S. [4]

Overview

In the 2016 update of the stable chest pain guideline, National Institute for Health and Clinical Excellence (NICE) has dramatically changed its approach to new-onset stable chest pain aiming to find a more cost-effective strategy including NO use of pretest probability risk scores or NO use of functional tests, such as stress echocardiography, as a first-line investigation. The suggestion is to use CT coronary angiography in [[patients] with typical or atypical chest pain. In addition, there is no recommendation for any diagnostic testing if chest pain is non-anginal. Also, perfusion imaging is offered in the setting of uncertainty about the functional significance of coronary lesions. However, the recommendation of the European Society of Cardiology (ESC—2013) is functional tests as the initial investigation.

NICE Guidelines for the Management of Patients with Acute Chest Pain [1]

  • If the patient is currently pain-free, but had chest pain in the last 12 hours, and resting 12-lead ECG is abnormal or not available or develops further chest pain after recent (confirmed or suspected) ACS, evaluation about ACS is warranted.
  • Management of ACS:
  • Assessment of patients with suspected ACS in the hospital:

· Repeated resting 12-lead ECGs · Checking pain relief

  • Use of high-sensitivity troponin tests is not recommended, if ACS is not suspected
  • For patients at high or moderate risk of MI (as indicated by a validated tool), performing high sensitivity troponin tests is reasonable.
  • For patients at low risk of MI :
  • Performing a second high-sensitivity troponin test
  • Considering a single high-sensitivity troponin test only at presentation to rule out NSTEMI , if the first troponin test is below the lower limit of detection (negative).
  • A detectable troponin on the first high-sensitivity test does not necessary for patients with confirmed MI.
  • For diagnose of ACS use of biochemical markers such as natriuretic peptides and high-sensitivity C-reactive protein are not recommended.

.

  • Factors should be considered for interpreting high-sensitivity troponin:
  • the clinical presentation
  • The time from onset of symptoms
  • The resting 12-lead ECG findings
  • The pre-test probability of NSTEMI
  • The length of time since the suspected ACS
  • The probability of chronically elevated troponin levels in some patients
  • That 99th percentile threshold for troponin I and T may differ between sexes.

References

  1. ↑ Carrabba N, Migliorini A, Pradella S, Acquafresca M, Guglielmo M, Baggiano A, Moscogiuri G, Valenti R (2018). "Old and New NICE Guidelines for the Evaluation of New Onset Stable Chest Pain: A Real World Perspective". Biomed Res Int. 2018: 3762305. doi:10.1155/2018/3762305. PMC 6250018. PMID 30533431.


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