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: 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

• 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

• 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

• 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.
• 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

• 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] patients 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 abnormalities

  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

• 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 the European Society of Cardiology (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

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