NICE guidelines for management of chest pain: Difference between revisions

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===Key priorities for implementation in patients with Acute Chest Pain===
===Key priorities for implementation in patients with Acute Chest Pain===
* Take a '''resting 12-lead electrocardiogram''' (ECG) as soon as possible.
* Take a resting 12-lead electrocardiogram (ECG) as soon as possible.
* When people are referred, send the results to hospital before they arrive if possible.
* When people are referred, send the results to hospital before they arrive if possible.
* Recording and sending the ECG should not delay transfer to hospital.
* Recording and sending the ECG should not delay transfer to hospital.
* '''Do not exclude an acute coronary syndrome (ACS) when people have a normal resting 12-lead ECG.'''
* Do not exclude an acute coronary syndrome (ACS) when people have a normal resting 12-lead ECG.
* 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:
* 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:
** '''People with oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94–98%'''
** People with oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94–98%.
** '''People with 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.'''
** People with 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.
* 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.
* 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.
===Key priorities for implementation in patients with Stable Chest Pain===
===Key priorities for implementation in patients with Stable Chest Pain===
Line 21: Line 21:
** Clinical assessment alone or
** Clinical assessment alone or
** Clinical assessment plus diagnostic testing (that is, anatomical testing for obstructive coronary artery disease [CAD] and/or functional testing for myocardial ischaemia).
** Clinical assessment plus diagnostic testing (that is, anatomical testing for obstructive coronary artery disease [CAD] and/or functional testing for myocardial ischaemia).
** '''If people have features of typical angina based on clinical assessment and their estimated likelihood of CAD is greater than 90%, further diagnostic investigation is unnecessary. Manage as angina.'''
** If people have features of typical angina based on clinical assessment and their estimated likelihood of CAD is greater than 90%, further diagnostic investigation is unnecessary. Manage as angina.
** Unless clinical suspicion is raised based on other aspects of the history and risk factors, '''exclude a diagnosis of stable angina if the pain is non-anginal'''. Other features which make a diagnosis of stable angina unlikely are when the chest pain is:
** Unless clinical suspicion is raised based on other aspects of the history and risk factors, exclude a diagnosis of stable angina if the pain is non-anginal. Other features which make a diagnosis of stable angina unlikely are when the chest pain is:
*** '''Continuous or very prolonged and/or'''
*** Continuous or very prolonged and/or
*** '''Unrelated to activity and/or'''
*** Unrelated to activity and/or
*** '''Brought on by breathing in and/or'''
*** Brought on by breathing in and/or
*** '''Associated with symptoms such as dizziness, palpitations, tingling or difficulty swallowing'''
*** Associated with symptoms such as dizziness, palpitations, tingling or difficulty swallowing


* Consider causes of chest pain other than angina (such as gastrointestinal or musculoskeletal pain).
* Consider causes of chest pain other than angina (such as gastrointestinal or musculoskeletal pain).
* In people without confirmed coronary artery disease (CAD), in whom stable angina cannot be diagnosed or excluded based on clinical assessment alone, estimate the likelihood of CAD. Take the clinical assessment and the resting 12-lead ECG into account when making the estimate. Arrange further diagnostic testing as follows:
* In people without confirmed coronary artery disease (CAD), in whom stable angina cannot be diagnosed or excluded based on clinical assessment alone, estimate the likelihood of CAD. Take the clinical assessment and the resting 12-lead ECG into account when making the estimate. Arrange further diagnostic testing as follows:
** '''If the estimated likelihood of CAD is 61–90%, offer invasive coronary angiography as the first-line diagnostic investigation if appropriate.'''
** If the estimated likelihood of CAD is 61–90%, offer invasive coronary angiography as the first-line diagnostic investigation if appropriate.
** '''If the estimated likelihood of CAD is 30–60%, offer functional imaging as the first-line diagnostic investigation.'''
** If the estimated likelihood of CAD is 30–60%, offer functional imaging as the first-line diagnostic investigation.
** '''If the estimated likelihood of CAD is 10–29%, offer CT calcium scoring as the first-line diagnostic investigation.'''
** If the estimated likelihood of CAD is 10–29%, offer CT calcium scoring as the first-line diagnostic investigation.
* Do not use exercise ECG to diagnose or exclude stable angina for people without known CAD.
* Do not use exercise ECG to diagnose or exclude stable angina for people without known CAD.


Revision as of 17:07, 26 February 2013

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

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.

NICE guidelines for the management of patients with Chest pain (DO NOT EDIT) [1]

“

Key priorities for implementation in patients with Acute Chest Pain

  • Take a resting 12-lead electrocardiogram (ECG) as soon as possible.
  • When people are referred, send the results to hospital before they arrive if possible.
  • Recording and sending the ECG should not delay transfer to hospital.
  • Do not exclude an acute coronary syndrome (ACS) when people have a normal resting 12-lead ECG.
  • 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:
    • People with oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94–98%.
    • People with 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.
  • 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.

Key priorities for implementation in patients with Stable Chest Pain

  • Diagnose stable angina based on one of the following:
    • Clinical assessment alone or
    • Clinical assessment plus diagnostic testing (that is, anatomical testing for obstructive coronary artery disease [CAD] and/or functional testing for myocardial ischaemia).
    • If people have features of typical angina based on clinical assessment and their estimated likelihood of CAD is greater than 90%, further diagnostic investigation is unnecessary. Manage as angina.
    • Unless clinical suspicion is raised based on other aspects of the history and risk factors, exclude a diagnosis of stable angina if the pain is non-anginal. Other features which make a diagnosis of stable angina unlikely are when the chest pain is:
      • Continuous or very prolonged and/or
      • Unrelated to activity and/or
      • Brought on by breathing in and/or
      • Associated with symptoms such as dizziness, palpitations, tingling or difficulty swallowing
  • Consider causes of chest pain other than angina (such as gastrointestinal or musculoskeletal pain).
  • In people without confirmed coronary artery disease (CAD), in whom stable angina cannot be diagnosed or excluded based on clinical assessment alone, estimate the likelihood of CAD. Take the clinical assessment and the resting 12-lead ECG into account when making the estimate. Arrange further diagnostic testing as follows:
    • If the estimated likelihood of CAD is 61–90%, offer invasive coronary angiography as the first-line diagnostic investigation if appropriate.
    • If the estimated likelihood of CAD is 30–60%, offer functional imaging as the first-line diagnostic investigation.
    • If the estimated likelihood of CAD is 10–29%, offer CT calcium scoring as the first-line diagnostic investigation.
  • Do not use exercise ECG to diagnose or exclude stable angina for people without known CAD.

Providing Information for People with Chest Pain

  • Discuss any concerns people (and where appropriate their family or carer/advocate) may have, including anxiety when the cause of the chest pain is unknown. Correct any misinformation.
  • Offer people a clear explanation of the possible causes of their symptoms and the uncertainties.
  • Clearly explain the options to people at every stage of investigation. Make joint decisions with them and take account of their preferences:
  • Encourage people to ask questions.
  • Provide repeated opportunities for discussion.
  • Explain test results and the need for any further investigations.
  • Provide information about any proposed investigations using every day, jargon-free language. Include:
  • Their purpose, benefits and any limitations of their diagnostic accuracy
    • Duration
    • Level of discomfort and invasiveness
    • Risk of adverse events
  • Offer information about the risks of diagnostic testing, including any radiation exposure.
  • Address any physical or learning difficulties, sight or hearing problems and difficulties with speaking or reading English, which may affect people's understanding of the information offered.
  • Offer information after diagnosis as recommended in the relevant disease management guidelines*
  • Explain if the chest pain is non-cardiac and refer people for further investigation if appropriate.
  • Provide individual advice to people about seeking medical help if they have further chest pain.


 ”

NICE guidelines for the management of patients with acute chest pain (DO NOT EDIT) [1]

NICE guidelines for the management of patients with acute chest pain

NICE guidelines for the management of patients with stable chest pain (DO NOT EDIT) [1]

NICE guidelines for the management of patients with stable chest pain

References

  1. ↑ 1.0 1.1 1.2 [[]]. PMID 22420013. Missing or empty |title= (help); |access-date= requires |url= (help)


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