NICE guidelines for management of chest pain

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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

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 the majority of patients whether no diagnostic testing if chest pain is non-anginal and CT coronary angiography (CTCA) in patients with typical or atypical chest pain with additional perfusion imaging in the setting of uncertainty about the functional significance of coronary lesions. However, the recommendation of the European Society of Echocardiography (ESC—2013) is functional tests as the initial investigation.

NICE Guidelines for the Management of Patients with Chest Pain

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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.

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NICE Guidelines for the Management of Patients with Acute Chest Pain

• NICE guidelines for the management of patients with acute chest pain

Investigation and diagnosis of acute chest pain in hospital

Assessment of acute chest pain in hospital Clinical history Physical examination Resting 12 leads ECG hs-troponin on arrival Risk stratification

Normal resting ECG or non-diagnostic

ECG changes consistent with NSTEMI

ECG changes consistent with STEMI

Low risk patient with undetectable hs-troponin level: Reassurance, discharge

Consider ACS by clinical judgment even in the presence of normal ECG Repeat hs-troponin level after 3 hours of arrival in hospital while diagnosis is not clear Serial ECG taken and clinically assessment of patient and considering the ECG changes Investigation regarding other life-threatening causes of chest pain NO need for routin non-invasive cardiac imaging or EX-ECG for initial evaluation Consider other differential diagnosis Consider hs-troponin level 3 hours after initiation of symptoms Consider an alternative diagnosis

NSTEMI, ACS Guideline follow-up

STEMI Guideline follow-up

hs-troponin concentration on arrival and at 3 hours bellow the cut-off measurement: Low risk patient, discharge

hs-troponin concentration on arrival and at 3 hours higher than cut-off measurement

Diagnostic criteria for MI

Yes: Rise and fall in cardiac biomarker, especially hs-troponin, with at least one of the following: Symptoms of ischemia Ischemic ECG changes including ST-T changes, new LBBB, pathologic Q waves Regional wall motion abnormalities on imaging study

NO: Consider CXR or Chest CT scan for evaluation of alternative diagnosis

The above algorithm adopted from 2016 NICE Guideline

NICE guidelines for the management of patients with stable chest pain

• NICE guidelines for the management of patients with stable chest pain

National Institute for Health and Clinical Excellence (NICE) has dramatically changed its guideline on approach to 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 in patients with new-onset stable chest pain. The suggestion is to use CT coronary angiography in the majority of patients. However, the recommendation of European Society of Echocardiography (ESC—2013) is functional tests as the initial investigation.

Assessment and detailed history Age, sex Characteristic of chest pain and associated symptoms History of angina, MI, cardiovascular disease, coronary revascularization Cardiac risk factors Consider non-coronary causes of angina (aortic stenosis, cardiomyopathy) Consider other causes of chest pain

Non anginal aspect of chest pain without cardiac risk factors or clinical suspicious

Typical or atypical anginal in clinical assessment

Indentify other causes of chest pain Only consider CXR if other causes are suspected

Consider resting ECG Obtaining blood sample testing Consider ASA while waiting for the preparation of test results Evaluation of other causes of chest pain including hypertrophic cardiomyopathy in the setting of typical chest pain and low likelihood of CAD

The above algorithm adopted from 2016 NICE Guideline

Consider 64 slice (or obove) Coronary CT Angiography in the presence of: Typical or atypical angina Non-angina chest pain, but evidence of ST-T changes or Q waves on resting 12 lead-ECG

Consider non-invasive functional imaging in the presence of: Inconclusive coronary CT angiography result Determining ischemia as the cause of chest pain when CAD is evident Exercise ECG can be used instead of functional imaging study in patients with confirm CAD Coronary angiography can be used when the imaging study result is inconclusive

Consider stable angina in the presence of obstructive CAD on coronary CT angiography or reversible ischemia on functional imaging study Consider other causes of chest pain in the absence of above findings

Stable chest pain: ❑ Typical stable angina symptoms: Constriction discomfort in the front of chest, shoulders, nech, jaw, arms Percipitated by exercise Relieved with rest or TNG within about 5 minutes ❑ Typical angina : all of the above ❑ Atypical angina: two of the above ❑ Non-anginal chest pain: non or one of the above

Stable angina is unlikely if chest pain is: ❑ Not related to the activity ❑ Very prolonged or continuous ❑ Exacerbated by inspiration ❑ Associated with dizziness, palpitations, tingling, difficulty in swallowing

ECG changes associated with CAD: ❑ LBBB ❑ Pathologic Q waves ❑ ST-T abnormalities Normal ECG does not rule out stable angina

Non-invasive functional imaging study for evaluation of myocardial ischemia: ❑Myocardial perfusion scintigraphy with single photon emission CT ( with adenosin, dipyridamole, dobutamine ❑ Stress echocardiography (with exercise or dobutamine ❑First pass contrast enhanced MR perfusion with adenosine or dipyridamole ❑ MR imaging with exercise or dobutamine

Definition of significant CAD: ❑Coronary CT angiography: ≥ 70% stenosis of any of major epicardial coronary arteries or ≥ 50% stenosis in left main coronary arteries ❑ Factors associated with intensifying ischemia in the lesions less than 50% Reduced oxygen delivery due to anemia, coronary artery spasm Increased oxygen demand by tachycardia, left ventricular hypertrophy< br> Large ischemia region of myocardium due to proximal coronary artery stenotic lesion Longer length of lesion ❑ Factors associated reduced ischemia in significant lesion ≥70 %: Well developed collateral supply Small ischemia region of myocardium due to fiat ally location of lesion , old infarction the territory of coronary supply

The above algorithm adopted from 2016 NICE Guideline

References

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