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 Cardiology (ESC—2013) is functional tests as the initial investigation.
NICE Guidelines for the Management of Patients with Acute Chest Pain[1]
- Symptoms suggestive od acute coronary syndromes:
- 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 hemodynamic 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
- 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:
- Transferring the patient to hospital immediately
- 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
- Physical examination to determine:
- Hemodynamic status
- Signs of complications, including pulmonary oedema, cardiogenic shock
- Signs of non-coronary causes of acute chest pain, such as aortic dissection
- Taking a detailed clinical history unless a STEMI is confirmed from the resting 12-lead ECG (regional ST-segment elevation or presumed new LBBB)
- The characteristics of the pain
- Other associated symptoms
- Any history of cardiovascular disease
- Routinely administration of oxygen is not recommended, but monitoring oxygen saturation and pulse oximetry as soon as possible, ideally, before hospital admission is recommended.
- Indications for supplemental oxygen:
- Oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94–98%
- 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.
- Patients with acute chest pain should be monitored for:
- Exacerbations of pain and/or other symptoms
- Pulse and blood pressure
- Heart rhythm
- Oxygen saturation by pulse oximetry
- Repeated resting 12-lead ECGs
- Checking pain relief
- Use of biochemical markers for diagnosis of an acute coronary syndrome:
- 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.
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- Cheching 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.
- 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 thresholds for troponin I and T may differ between sexes.
- Universal definition of myocardial infarction:
- 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:
- Symptoms of ischaemia
- New or presumed new significant ST-segment-T wave(ST-T) changes or new left bundle branch block (LBBB)
- Development of pathological Q waves in the ECG
- Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality
- Identification of an intracoronary thrombus by angiography
- 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)
- 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.
- Ifmyocardial ischemia is suspected, follow the recommendations on stable chest pain.
- Clinical judgment is important to decide on the timing of any further diagnostic investigations.
- Routinely use of non-invasive imaging or exercise ECG in the initial assessment of acute cardiac chest pain is not recommended.
- Chest computed tomography (CT) is recommended to rule out other diagnoses such as pulmonary embolism or aortic dissection, not to diagnose ACS.
- Chest X-ray is helpful to exclude complications of ACS such as pulmonary oedema, or other diagnoses such as pneumothorax or pneumonia.
- 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.
Management of patients with stable chest pain
Clinical assessment 1.3.2.1 Take a detailed clinical history documenting: · the age and sex of the person · the characteristics of the pain, including its location, radiation, severity, duration and frequency, and factors that provoke and relieve the pain · any associated symptoms, such as breathlessness · any history of angina, MI, coronary revascularisation, or other cardiovascular disease and · any cardiovascular risk factors. [2010] 1.3.2.2 Carry out a physical examination to identify risk factors for cardiovascular disease · identify signs of other cardiovascular disease · identify non-coronary causes of angina (for example, severe aortic stenosis, cardiomyopathy) and · exclude other causes of chest pain. [2010] 1.3.3 Making a diagnosis based on clinical assessment 1.3.3.1 Assess the typicality of chest pain as follows: · Presence of three of the features below is defined as typical angina. · Presence of two of the three features below is defined as atypical angina. · Presence of one or none of the features below is defined as non-anginal chest pain. Anginal pain is: · constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms · precipitated by physical exertion · relieved by rest or GTN within about 5 minutes. [2010, amended 2016] 1.3.3.2 Do not define typical and atypical features of anginal chest pain and non-anginal chest pain differently in men and women. [2010] 1.3.3.3 Do not define typical and atypical features of anginal chest pain and non-anginal chest pain differently in ethnic groups. [2010] 1.3.3.4 Take the following factors, which make a diagnosis of stable angina more likely, into account when estimating people’s likelihood of angina: · age · whether the person is male · cardiovascular risk factors including: o a history of smoking o diabetes o hypertension o dyslipidaemia o family history of premature CAD o other cardiovascular disease · history of established CAD, for example previous MI, coronary revascularisation. [2010] 1.3.3.5 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 (see recommendation 1.3.3.1). 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)1.3.3.6 Consider investigating other causes of angina, such as hypertrophic cardiomyopathy, in people with typical angina-like chest pain and a low likelihood of CAD. [ Arrange blood tests to identify conditions which exacerbate angina, such as anaemia, for all people being investigated for stable angina. [2010] 1.3.3.8 Only consider chest X-ray if other diagnoses, such as a lung tumour, are suspected. [2010] 1.3.3.9 If a diagnosis of stable angina has been excluded at any point in the care pathway, but people have risk factors for cardiovascular disease, follow the appropriate guidance, for example the NICE guideline on cardiovascular disease and the NICE guideline on hypertension in adults. [2010] 1.3.3.10 For people in whom stable angina cannot be excluded on the basis of the clinical assessment alone, take a resting 12-lead ECG as soon as possible after presentation. [2010, amended 2016] 1.3.3.11 Do not rule out a diagnosis of stable angina on the basis of a normal resting 12-lead ECG. [2010] 1.3.3.12 Do not offer diagnostic testing to people with non-anginal chest pain on clinical assessment (see recommendation 1.3.3.1) unless there are resting ECG ST-T changes or Q waves. [new 2016] 1.3.3.13 A number of changes on a resting 12-lead ECG are consistent with CAD and may indicate ischaemia or previous infarction. These include: · pathological Q waves in particular · LBBB · ST-segment and T wave abnormalities (for example, flattening or inversion). Note that the results may not be conclusive. Consider any resting 12-lead ECG changes together with people’s clinical history and risk factors. [2010] 1.3.3.14 For people with confirmed CAD (for example, previous MI, revascularisation, previous angiography) in whom stable angina cannot be excluded based on clinical assessment alone, see recommendation 1.3.4.4 about functional testing. [2010, amended 2016] 1.3.3.15 Consider aspirin only if the person’s chest pain is likely to be stable angina, until a diagnosis is made. Do not offer additional aspirin if there is clear evidence that people are already taking aspirin regularly or are allergic to it. [2010] 1.3.3.16 Follow local protocols for stable anginac while waiting for the results of investigations if symptoms are typical of stable angina. [2010] 1.3.4 Diagnostic testing for people in whom stable angina cannot be excluded by clinical assessment alone The Guideline Development Group emphasised that the recommendations in this guideline are to make a diagnosis of chest pain, not to screen for CAD. Most people diagnosed with non-anginal chest pain after clinical assessment need no further diagnostic testing. However in a very small number of people, there are remaining concerns that the pain could be ischaemic. 1.3.4.1 Include the typicality of anginal pain features (see recommendation 1.3.3.1) in all requests for diagnostic investigations and in the person’s notes. [2010, amended 2016] 1.3.4.2 Use clinical judgement and take into account people’s preferences and comorbidities when considering diagnostic testing. [2010] 1.3.4.3 Offer 64-slice (or above) CT coronary angiography if:Recent-onset chest pain of suspected cardiac origin Guideline summary National Institute for Health and Care Excellence , 2016 22 Update 2016 Update 2016 Update 2016 Update 2016 · clinical assessment (see recommendation 1.3.3.1) indicates typical or atypical angina, or · clinical assessment indicates non-anginal chest pain but 12-lead resting ECG has been done and indicates ST-T changes or Q waves. [new 2016] 1.3.4.4 For people with confirmed CAD (for example, previous MI, revascularisation, previous angiography), offer non-invasive functional testing when there is uncertainty about whether chest pain is caused by myocardial ischaemia. See section 1.3.6 for further guidance on non-invasive functional testing. An exercise ECG may be used instead of functional imaging. [2010] 1.3.5 Additional diagnostic investigations 1.3.5.1 Offer non-invasive functional imaging (see section 1.3.6) for myocardial ischaemia if 64-slice (or above) CT coronary angiography has shown CAD of uncertain functional significance or is non�diagnostic. [2016] 1.3.5.2 Offer invasive coronary angiography as a third-line investigation when the results of non�invasive functional imaging are inconclusive. [2016] 1.3.6 Use of non-invasive functional testing for myocardial ischaemia 1.3.6.1 When offering non-invasive functional imaging for myocardial ischaemia use: · myocardial perfusion scintigraphy with single photon emission computed tomography (MPS with SPECT) or · stress echocardiography or · first-pass contrast-enhanced magnetic resonance (MR) perfusion or · MR imaging for stress-induced wall motion abnormalities. Take account of locally available technology and expertise, the person and their preferences, and any contraindications (for example, disabilities, frailty, limited ability to exercise) when deciding on the imaging method. [This recommendation updates and replaces recommendation 1.1 of ‘Myocardial perfusion scintigraphy for the diagnosis and management of angina and myocardial infarction’ (NICE technology appraisal guidance 73)]. [2016] 1.3.6.2 Use adenosine, dipyridamole or dobutamine as stress agents for MPS with SPECT and adenosine or dipyridamole for first-pass contrast-enhanced MR perfusion. [2010] 1.3.6.3 Use exercise or dobutamine for stress echocardiography or MR imaging for stress-induced wall motion abnormalities. [2010] 1.3.6.4 Do not use MR coronary angiography for diagnosing stable angina. [2010] 1.3.6.5 Do not use exercise ECG to diagnose or exclude stable angina for people without known CAD. [2010] 1.3.7 Making a diagnosis following investigations Box 1 Definition of significant coronary artery disease Significant coronary artery disease (CAD) found during CT coronary angiography is ≥ 70% diameter stenosis of at least one major epicardial artery segment or ≥ 50% diameter stenosis in the left main coronary artery Consider investigating other causes of angina, such as hypertrophic cardiomyopathy or syndrome X, in people with typical angina-like chest pain if investigation excludes flow-limiting disease in the epicardial coronary arteries. [2010
NICE Guidelines for the Management of Patients with Acute Chest Pain [1]
Investigation and diagnosis of acute chest pain in hospital
Assessment of acute chest pain in hospital
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| 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
| 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: | NO:
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| The above algorithm adopted from 2016 NICE Guideline |
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NICE guidelines for the management of patients with stable chest pain[1]
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 the European Society of Cardiology (ESC—2013) is functional tests as the initial investigation.[2]
Assessment and detailed history
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| 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
| Consider resting ECG
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| The above algorithm adopted from 2016 NICE Guideline |
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Consider 64 slice (or obove) Coronary CT Angiography in the presence of:
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Consider non-invasive functional imaging in the presence of:
| Consider stable angina in the presence of obstructive CAD on coronary CT angiography or reversible ischemia on functional imaging study
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Stable chest pain: ❑ Typical stable angina symptoms:
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Stable angina is unlikely if chest pain is: ❑ Not related to the activity | |||||||||||||||||||||||
ECG changes associated with CAD: ❑ LBBB
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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:
❑ Factors associated with intensifying ischemia in the lesions less than 50%
❑ Factors associated reduced ischemia in significant lesion ≥70 %:
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| The above algorithm adopted from 2016 NICE Guideline |
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References
- ↑ 1.0 1.1 1.2 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.
- ↑ Timmis A, Roobottom CA (July 2017). "National Institute for Health and Care Excellence updates the stable chest pain guideline with radical changes to the diagnostic paradigm". Heart. 103 (13): 982–986. doi:10.1136/heartjnl-2015-308341. PMID 28446550.