NICE guidelines for the management of patients with stable chest pain

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 offered 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.

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.

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