NICE guidelines for management of 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.


==NICE Guidelines for the Management of Patients with Chest Pain (DO NOT EDIT)<ref name="pmid22420013">{{cite journal |author= |title= |journal=[[]] |volume= |issue= |pages= |year= |pmid=22420013 |doi= |url= |accessdate=2012-05-08}}</ref>==
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 recommended in the setting of uncertainty about the functional significance of [[coronary]] lesions. However, the recommendation of the [[European Society of Cardiology]] ([[ESC]]—2013) is performing functional tests as the initial investigation.
{{cquote|


===Key Priorities for Implementation in Patients with Acute Chest Pain===
==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> ==
* 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 (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%.
** 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.
* 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===
::* Symptoms suggestive od [[acute coronary syndromes]]:
* Diagnose stable angina based on one of the following:
*Pain in the [[chest]] and/or other areas (for example, the [[arms]], [[back]] or [[jaw]]) lasting longer than 15 minutes ·
** Clinical assessment alone or
*[[Chest pain]] associated with [[nausea]] and [[vomiting]], marked [[sweating]], [[breathlessness]], or particularly a combination of these ·
** Clinical assessment plus diagnostic testing (that is, anatomical testing for obstructive coronary artery disease [CAD] and/or functional testing for myocardial ischaemia).
* [[Chest pain]] associated with [[hemodynamic]] instability ·
** 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.
* 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
** 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).
::* 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.
* 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===
::* Management of [[ACS]]:
* 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.
* Transferring the [[patient]] to [[hospital]] immediately 
* Offer people a clear explanation of the possible causes of their symptoms and the uncertainties.
*Taking a resting 12-lead [[ECG]] ·
* Clearly explain the options to people at every stage of investigation. Make joint decisions with them and take account of their preferences:
* Managing pain with [[TNG]] and/or an [[opioid]]
* Encourage people to ask questions.
*Giving a single dose of 300 mg [[aspirin]] unless the person is [[allergic]], and other neccessary therapeutic interventions
* Provide repeated opportunities for discussion.
* Checking  [[oxygen saturation]] and administer [[oxygen]] if appropriate  
* Explain test results and the need for any further investigations.
* Monitoring the [[patient]]
* 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.


}}
::* Assessment of [[patients]] with suspected [[ACS]] in the hospital:
*[[ 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]]


==NICE Guidelines for the Management of Patients with Acute Chest Pain (DO NOT EDIT)<ref name="pmid22420013">{{cite journal |author= |title= |journal=[[]] |volume= |issue= |pages= |year= |pmid=22420013 |doi= |url= |accessdate=2012-05-08}}</ref>==
* 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.
.
* 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]].
*If[[ myocardial 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
*Taking a detailed clinical [[history]] about:
*  [[age]] and [[sex]]
* Characteristics of the pain, including location, radiation, severity, duration, frequency,
* Provoking and relieving factors
*  Associated symptoms, such as [[breathlessness]]
*History of [[angina]], [[MI]], [[coronary revascularization]], or other [[cardiovascular disease]]
* [[Cardiovascular]] risk factors
*:: [[Physical examination]] to
*identifying risk factors for [[cardiovascular disease]]
* identifying signs of another [[cardiovascular disease]]
* identifying non-coronary causes of [[angina]] ( severe [[aortic stenosis]], [[cardiomyopathy]])
* excluding other causes of [[chest pain]]
 
* Assessment of  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 [[TNG]] within about 5 minutes
* Typical and atypical features of anginal [[chest pain]] and non-anginal [[chest pain]] are not defined
differently in [[men]] and [[women]] in [[ethnic]] groups.
*: Stable [[angina]] is  more likely based on characteristics of:
* [[Age]]
* [[Male ]] [[sex]]
* [[Cardiovascular]] risk factors including:
*[[Smoking]]
* [[Diabetes]]
* [[Hypertension]]
* [[Dyslipidemia]]
*[[Family history]] of premature [[CAD]]
* other [[cardiovascular]] disease
* History of established [[CAD]], for example previous [[MI]], [[coronary revascularization]]
 
*Features that make a diagnosis of [[stable angina]] unlikely are when the [[chest pain]] is:
* Continuous or very prolonged
*Unrelated to activity
* Increased by [[inspiration]]
* Associated with [[symptoms]] such as [[dizziness]], [[palpitations]], [[tingling ]] or difficulty [[swallowing]]
*Considering causes of [[chest pain]] other than angina (such as [[gastrointestinal]] or [[musculoskeletal pain]])
* Investigating other causes of [[angina]], such as [[hypertrophic cardiomyopathy]], in [[patients]] with typical angina-like [[chest pain]] and a low likelihood of [[CAD]] is considered.
* Factors that exacerbate [[angina]], such as [[anemia]], for all [[patients]] with [[stable angina]] should be considered.
*Only consider [[chest X-ray]] if other diagnoses, such as a [[lung tumor]], are suspected.
* If a diagnosis of [[stable angina]] has been excluded, but [[the] [[patient]]s have risk factors for [[cardiovascular disease]], follow the appropriate guidance, for example the NICE  guideline on [[hypertension]].
* For [[suspected]] stable angina on the basis of the clinical assessment alone, taking a resting 12-lead [[ECG]] as soon as possible after the presentation is recommended.
* The diagnosis of [[stable angina ]] is not ruled out on the basis of a normal resting 12-lead [[ECG]].
* For [[patients]] with non-anginal [[chest pain]] on clinical assessment, [[diagnostic testing]] is not recommended, unless there are resting ECG ST-T changes or Q waves.
* Resting 12-lead [[ECG]] changes consistent with [[CAD ]] are:
*[[Ischaemia]] or previous [[infarction]]
* Pathological Q waves
* [[LBBB]]
* [[ST-segment ]] and [[T wave abnormalities]] ( flattening or inversion).
*: Any resting 12-lead [[ECG ]] changes together with people’s clinical history and risk factors should be considered.
 
 
*:  Consider [[aspirin]] only if the  [[chest pain]] is likely to be stable angina until a diagnosis is made.
*If the [[patient]] is already taking [[aspirin]] or is allergic to it, do not offer additional [[aspirin]].
 
*The Guideline Development Group emphasized 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]].
*:: 64-slice (or above) CT coronary angiography is recommended in the presence of:
* Recent-onset [[chest pain]] of suspected [[cardiac]] origin
* Clinical assessment indicating typical or [[atypical angina]]
* Clinical assessment indicating non-anginal [[chest pain]] but ST-T changes or Q waves in resting [[ECG]]
*: For [[patients]] with confirmed [[CAD]] ( previous [[MI]], [[revascularization]], previous [[angiography]]), non-invasive functional testing  is recommended when there is uncertainty about whether [[chest pain]] is caused by [[myocardial ischaemia]].
* An [[exercise ECG]] may be used instead of functional imaging.
* Non-invasive functional imaging for [[myocardial ischemia]] is recommended if 64-slice (or above) CT coronary angiography has shown [[ CAD ]] of uncertain functional significance or is nondiagnostic.
* [[Invasive coronary angiography]]  is offered as a third-line investigation when the results of non-invasive functional imaging are inconclusive.
*: Use of non-invasive functional testing for [[myocardial ischemia]]
* [[Myocardial perfusion scintigraphy]] with [[single-photon emission] computed tomography [[(MPS]] with [[SPECT]]) or
* [[Stress echocardiography]]
* First-pass contrast-enhanced [[magnetic resonance]] (MR) perfusion
*[[ MR imaging]] for stress-induced [[wall motion abnormalitie]]s
*:: Consider 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.
 
* Use [[adenosine]], [[dipyridamole]], or [[dobutamine]] as stress agents for [[MPS]] with [[SPECT]] and
[[adenosine]] or [[dipyridamole]] for first-pass contrast-enhanced [[MR perfusion]].
* Use [[exercise]] or [[dobutamine]] for [[stress echocardiography]] or MR imaging for stress-induced
[[wall motion abnormalities]].
* Use of MR [[coronary angiography]] for diagnosing [[stable angina]] is not recommended.
* Use  of [[exercise ECG]] to diagnose or exclude [[stable angina]] for [[patients]] without known [[CAD]] is not recommended.
*::Definition of [[CAD]]:
*Significant [[coronary artery disease]] ([[CAD]]) in CT coronary angiography  ≥ 70%
*Diameter stenosis of at least one major [[epicardial artery]] segment or ≥ 50% diameter stenosis in the [[left main coronary artery]]
*::  Investigation about other causes of angina, such as [[hypertrophic cardiomyopathy]] or [[syndrome X]] is recommended in [[patients]] with typical angina-like [[chest pain]] if investigation excludes flow-limiting
disease in the [[epicardial coronary arteries]].
 
==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]]'''
*'''[[NICE guidelines for the management of patients with acute chest pain]]'''
==Investigation and diagnosis of acute [[chest pain]] in [[hospital]]==
==Investigation and diagnosis of acute [[chest pain]] in [[hospital]]==
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{{familytree | | | | | | | | | A01 | | | | | |A01=Assessment of acute [[chest pain]] in hospital
*Clinical [[history]]
*Clinical [[history]]
*[[Physical examination]]
*[[Physical examination]]
* Resting 12 leads [[ECG]]
* Resting 12 leads [[ECG]]
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==NICE guidelines for the management of patients with stable chest pain (DO NOT EDIT)<ref name="pmid22420013">{{cite journal |author= |title= |journal=[[]] |volume= |issue= |pages= |year= |pmid=22420013 |doi= |url= |accessdate=2012-05-08}}</ref>==
==NICE guidelines for the management of patients with stable 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 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 the European
Society of Cardiology ([[ESC]]—2013) is functional tests as the initial investigation.<ref name="pmid28446550">{{cite journal |vauthors=Timmis A, Roobottom CA |title=National Institute for Health and Care Excellence updates the stable chest pain guideline with radical changes to the diagnostic paradigm |journal=Heart |volume=103 |issue=13 |pages=982–986 |date=July 2017 |pmid=28446550 |doi=10.1136/heartjnl-2015-308341 |url=}}</ref>




Latest revision as of 13:32, 12 March 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 recommended in the setting of uncertainty about the functional significance of coronary lesions. However, the recommendation of the European Society of Cardiology (ESC—2013) is performing functional tests as the initial investigation.

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

  • 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:
  • Assessment of patients with suspected ACS in the hospital:
  • 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 thresholds for troponin I and T may differ between sexes.

Management of patients with stable chest pain

Clinical assessment

  • Assessment of 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:

differently in men and women in ethnic groups.


  • Consider aspirin only if the chest pain is likely to be stable angina until a diagnosis is made.
  • If the patient is already taking aspirin or is allergic to it, do not offer additional aspirin.
  • The Guideline Development Group emphasized 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.

contraindications (for example, disabilities, frailty, limited ability to exercise) when deciding on the imaging method.

adenosine or dipyridamole for first-pass contrast-enhanced MR perfusion.

wall motion abnormalities.

disease in the epicardial coronary arteries.

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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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:
 
 
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[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
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    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:
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    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
  • Consider other causes of chest pain in the absence of above findings


    •  
     
     
     
    Stable chest pain:

    ❑ Typical stable angina symptoms:

     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    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

     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    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 %:

    • 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

    1. ↑ 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.
    2. ↑ 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.


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