WIREDGOV

New guidelines from the National Institute for Health and Clinical Excellence (NICE) are set to have a significant impact on reducing premature deaths by improving the assessment and diagnosis of patients with recent onset chest pain/discomfort that may be of cardiac origin. The guideline, jointly developed with the National Clinical Guidelines Centre for Acute and Chronic Conditions, represents a significant change in practice in some key areas of diagnosing an acute coronary syndrome (ACS) and angina. It will be important for the timely and accurate diagnosis of patients with this condition and will ensure that they receive the best possible treatment. Acute coronary syndrome encompasses a range of conditions from unstable angina to heart attacks.

Unlike many other NICE clinical guidelines, this guideline does not make recommendations for the management of the condition once the diagnosis has been made. Instead, its focus is on the diagnosis of chest pain which is suspected to be of cardiac origin, so that appropriate treatment can be provided to those with an ACS or stable angina. Clearer, early diagnosis will help ensure that patients with chest pain get the treatment they need, and that others avoid unnecessary investigations or treatment. The NICE guideline on unstable angina and non-ST-segment myocardial infarction (NSTEMI) is also published today and covers treatment of some patients with an ACS once a diagnosis has been made.

Chest pain is a very common symptom with some 20-40% of the general population experiencing it during their lives. In this country, chest pain accounts for up to 1% of visits to GPs, approximately 700,000 visits (5%) to emergency departments and up to 25% of emergency admissions to hospital. Importantly, in patients with chest pain due to an acute coronary syndrome (ACS) or angina, there are effective treatments to improve symptoms and prolong life.

The guideline has two separate diagnostic pathways. The first is for patients with acute chest pain who may have an ACS (such as a heart attack or unstable angina) and the second is for those with intermittent stable chest pain of suspected cardiac origin who may have stable angina. Recommendations in the guideline for people with acute chest pain and suspected ACS include:

• Take a resting 12-lead 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 ACS when people have 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, to guide the use of supplemental oxygen.
• Do not assess symptoms of an ACS differently in different ethnic groups.

Recommendations for people with intermittent stable chest pain who may have stable angina include:

• Diagnose stable angina based on either clinical assessment alone or where there is uncertainty, clinical assessment plus diagnostic testing (that is, anatomical testing for obstructive coronary artery disease CAD and/or functional testing for myocardial ischaemia (where the blood supply to the heart is restricted).
• 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 and should be managed 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 and first consider causes of pain other than angina (such as gastrointestinal or musculoskeletal pain).
• In people without confirmed CAD, in whom a diagnosis of stable angina cannot be made or excluded based on clinical assessment alone, estimate the likelihood of CAD, taking into account the clinical assessment and the resting 12-lead ECG. Arrange further diagnostic testing according to the estimated likelihood of CAD.
• Do not use exercise ECG to diagnose or exclude stable angina for people without known CAD.

Dr Gillian Leng, NICE Deputy Chief Executive, said:“This new guideline compiles evidence-based recommendations on best practice in the assessment and diagnosis of people who have chest pain that may be of cardiac origin. Its overall aim is not just to provide these people with a timely and accurate assessment and diagnosis of their condition, but it is also about providing reassurance and information to patients and their carers at what can be a time of great anxiety.”

Professor Liam Smeeth, GP and member of the Guideline Development Group, said: Weknow that your chance of surviving a heart attack depends on how quickly you get treatment. This guideline will help ensure people get the treatment they need when they need it.”

Dr Jane Skinner, Consultant Community Cardiologist and clinical advisor to the Guideline Development Group, said: “Heart disease is a major cause of preventable death in the UK. This guideline will help ensure that people with chest pain of suspected cardiac origin have an accurate and timely diagnosis so that they can receive the treatments we know can make a significant difference to their outcome.”

Professor Adam Timmis, Consultant Interventional Cardiologist and Chair of the Guideline Development Group, said: “This guideline emphasises the central role of the initial clinical assessment in diagnosing cardiac causes of chest pain. It provides objective clinical criteria for determining whether diagnostic testing is necessary and if so what test should be used. The guideline will improve clinical decision making in patients with suspected angina, identifying those who might benefit from treatment to reduce risk and improve outcomes.”

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