Jane Skinner

NICE guidance. Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin

Chest pain is a very common symptom; 20% to 40% of the general population will experience chest pain during their lives,1 and in the UK, up to 1% of visits to a general practitioner are because of chest pain.2 Approximately 700 000 visits (5%) to the emergency department in England and Wales and up to 25% of emergency hospital admissions are because of chest pain.3 There are many causes of chest pain, some of which are benign, while others are potentially life threatening. Importantly, in patients with chest pain caused by an acute coronary syndrome (ACS) or angina, there are effective treatments to improve symptoms and prolong life, emphasising the importance of making timely and accurate diagnoses in patients in whom chest pain may be of cardiac origin. This guideline4 addresses the assessment and diagnosis of patients with recent onset chest pain/discomfort that may be of cardiac origin. Unlike many other National Institute for Health and Clinical Excellence (NICE) clinical guidelines it does not make recommendations for the management of the condition once the diagnosis is made. The NICE unstable angina and NSTEMI clinical guideline5 was published at the same time as the chest pain guideline, and a NICE clinical guideline for the management of angina is currently being prepared.6 The guideline has two separate diagnostic pathways. The first is for patients with acute chest pain who may have an ACS and the second for those with intermittent stable chest pain who may have stable angina. The guideline deals with chest pain of suspected cardiac origin. Thus, for example, the guideline does not apply to patients with pain considered to be caused by recent trauma to the chest. However, many patients presenting with chest pain do not have such clearly apparent alternative explanations and need …

Assessment of recent onset chest pain or discomfort of suspected cardiac origin: summary of NICE guidance.

Chest pain is very common, and in the United Kingdom about 1% of visits to a general practitioner, 5% of visits to the emergency department, and 25% of emergency hospital admissions are for this symptom.1 Chest pain has many causes, and when the cause could be cardiac in origin, appropriate and timely assessment and diagnostic investigation are needed. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin.2 NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the experience and opinion of the Guideline Development Group (GDG) on what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. Two separate diagnostic pathways are presented. The first is for people with acute chest pain in whom an acute coronary syndrome is suspected. The second is for people with intermittent stable chest pain in whom stable angina is suspected. ### Acute chest pain and suspected acute coronary syndrome #### Initial clinical assessment and referral to hospital

NICE clinical guideline: chest pain of recent onset

Chest pain is a common presentation in general practice: in the UK, up to 1% of visits to a GP are due to chest pain.1 Chest pain matters: the risk of death is doubled in the year following a new presentation with chest pain in general practice.1 The recently published guideline from the National Institute for Health and Clinical Excellence (NICE), Chest Pain of Recent Onset: Assessment and Diagnosis of Recent Onset Chest Pain or Discomfort of Suspected Cardiac Origin ,2 addresses the assessment and diagnosis of patients with recent-onset chest pain (or discomfort) that may be of cardiac origin. It does not make recommendations for the management of the condition once the diagnosis is made. The NICE unstable angina and non-ST elevation myocardial infarction (NSTEMI) clinical guideline3 was published at the same time as the chest pain guideline; local protocols are recommended for management of STEMI, and a NICE clinical guideline for the management of stable angina is currently being prepared.4 The chest pain guideline has two separate diagnostic pathways. The first is for patients with acute chest pain who may have an acute coronary syndrome (ACS), and the second for those with intermittent stable chest pain who may have stable angina. The need to provide information to patients (and, where appropriate, their family or carer/advocate) and to involve them in decisions is emphasised throughout. The recommendations around acute and ‘acute but not current’ (that is, recent pain but currently pain free) chest pain are summarised in Boxes 1 and 2. For chronic stable chest pain, a key aspect of the guideline of particular relevance to primary care is the recommendation that formal risk stratification of the likelihood of coronary artery disease (CAD) be undertaken, based on aspects of the history (Box 3 …

Outpatient cardiac catheterisation

Cardiac catheterisation is increasingly performed in an outpatient setting. The majority of series of outpatient cardiac catheterisation are in laboratories with immediate access to cardiovascular surgery. However, some units may be sited more distantly, although still generally close to a hospital. Compared to an inpatient procedure, outpatient cardiac catheterisation increases bed availability and there are considerable financial rewards with suggested savings of 11-54% of inpatient costs. Most patients are satisfied with an outpatient procedure and, although a quarter may have unanswered questions afterwards, this level may not differ from that found with inpatients. No study has been large enough to detect differences in the major complication rate which occur infrequently in whichever setting, and there is considerable variation between studies in the incidence of minor complications after outpatient procedures. In the only study which randomised all eligible patients to an inpatient (189 patients) or outpatient (192 patients) procedure, seven outpatients (3.6%) suffered bleeding or developed haematomas at the site of percutaneous femoral artery puncture towards the end of the mobilisation period and one patient was syncopal. These events were thought to be a direct result of the procedure being carried out in the outpatient setting. The proportion of patients considered eligible for outpatient cardiac catheterisation varies widely between different series from 20% to more than 80%. Whereas some of this variation may result from the implementation of different exclusion criteria for patients with potentially severe disease, the differences are so large that it is likely that different populations were studied. Unplanned admission rates varied from less than 1% to nearly 19%. With the currently available data no absolute guidelines can be derived to exclude all patients at risk of complications, but the American College of Cardiology/American Heart Association (ACC/AHA) task force recently published guidelines which identified low risk patients suitable for outpatient procedures. These guidelines have been used to select patients for investigation in two mobile units in the USA, and only 0.9% required urgent transfer for clinical instability, and 0.6% developed major complications. However, most patients did not need referral to a tertiary centre for additional procedures and there may be less scope for selecting patients within the ACC/AHA guidelines in the UK compared with the USA.

Impact of using different guideline recommended serum natriuretic peptide thresholds on the diagnosis and referral rates of a diagnostic heart failure clinic

The aims of this study were to determine the diagnostic yield of a dedicated heart failure diagnosis clinic and the impact of using different guideline recommended N‐terminal pro B‐type natriuretic peptide (NT‐proBNP) referral thresholds on diagnosis and referral patterns.

A novel cardiac output response to stress test developed to improve diagnosis and monitoring of heart failure in primary care.

Primary care physicians lack access to an objective cardiac function test. This study for the first time describes a novel cardiac output response to stress (CORS) test developed to improve diagnosis and monitoring of heart failure in primary care and investigates its reproducibility.

Baseline clinical profile and rapid progression to insulin treatment in newly diagnosed diabetic patients over 50 years of age

Cardiovascular disease is very common among newly diagnosed middle aged and elderly diabetic patients and causes substantial morbidity. Most of these patients will have type 2 diabetes. However type 1 diabetes can occur at all ages and insulin treatment can be inappropriately deferred in older newly diagnosed patients. We examined the records of all new diabetic patients between 1994 and 1997, aged over 50 years and within 6 months of diagnosis, to determine their presenting cardiovascular profile and baseline factors which might predict rapid progression to insulin treatment. We identified 455 patients and 371 had 2 year follow-up data. 71% had a blood pressure greater than 150 and/or 85 mm Hg, 70% had a cholesterol>5.0 mmol/L and 28% had diagnosed ischaemic heart disease. Within 2 years (8±2 months), 22 (6%) had progressed to insulin treatment. Predictive factors for insulin were presentation HbA1c (risk ratio 1.36, p<0.001), ketonuria (1.6, p<0.05) and the BMI/HbA1c ratio (0.23, p<0.0001) but not BMI alone. In conclusion, new diabetic patients aged over 50 years are at high cardiovascular risk. Progression to insulin treatment within 2 years of first clinic contact is uncommon. However, presenting HbA1c and especially the BMI/HbA1c ratio are strong predictors. Copyright