Intended for healthcare professionals

Practice Guidelines

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

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1118 (Published 24 March 2010) Cite this as: BMJ 2010;340:c1118
  1. Angela Cooper, senior research fellow1,
  2. Adam Timmis, professor of clinical cardiology 2,
  3. Jane Skinner, consultant community cardiologist3
  4. on behalf of the Guideline Development Group
  1. 1National Clinical Guideline Centre, Royal College of Physicians of London, London NW1 4LE
  2. 2Barts and the London Queen Mary’s School of Medicine and Dentistry, London E1 2AD
  3. 3Department of Cardiology, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP
  1. Correspondence to: A Cooper angela.cooper{at}rcplondon.ac.uk

    Why read this summary?

    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

    Recommendations

    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

    • Consider the history of chest pain, the presence of cardiovascular risk factors, history of ischaemic heart disease, and any previous investigations.[Based on moderate quality evidence from meta-analyses in one systematic review and one small cohort]

    • Assess for any of the following symptoms, which may indicate an acute coronary syndrome:

      • - Pain in the chest or other areas that lasts longer than 15 minutes

      • - Chest pain associated with nausea and vomiting, marked sweating, breathlessness, or a combination of these

      • - Chest pain associated with haemodynamic instability

      • - New onset chest pain, or abrupt deterioration in previously stable angina, with frequent recurrent pain that occurs with little or no exertion and often lasts longer than 15 minutes. [All recommendations based on high quality evidence from meta-analyses in three systematic reviews and one small cohort study]

    • Do not assess symptoms of an acute coronary syndrome differently in men and women [Based on moderate quality evidence from two systematic reviews, three cohort studies, and one retrospective cohort study] and different ethnic groups. [Based on moderate quality evidence from five cohort studies]

    • Do not use people’s response to glyceryl trinitrate to make a diagnosis. [Based on moderate quality evidence from three cohort studies and one small retrospective cohort study]

    • If an acute coronary syndrome is suspected, referral to hospital may be necessary (table 1). [Based on high quality evidence from meta-analyses in four systematic reviews, one cohort study, and one small cohort study]

    Table 1

     Referral to hospital if an acute coronary syndrome is suspected

    View this table:

    Immediate management of suspected acute coronary syndrome

    • Offer pain relief with glyceryl trinitrate (sublingual or buccal) or intravenous opioids, or both. [Based on low quality evidence from four small randomised controlled trials, one cohort study, and one small cohort study] Consider a single loading dose of 300 mg aspirin. [Based on the experience and opinion of the GDG]

    • Do not routinely administer oxygen. [Based on moderate quality evidence from one systematic review and two small cohort studies] Offer supplemental oxygen only according to British Thoracic Society guidelines.3

    Resting 12 lead ECG and hospital assessment for people with suspected acute coronary syndrome

    • Perform resting 12 lead electrocardiography (ECG) as soon as possible. [Based on high quality evidence from meta-analyses in three systematic reviews and one small cohort study] If in the community setting send the results to hospital [Based on high quality evidence in meta-analyses from one systematic review and one cohort study], but do not delay transfer to hospital.

    • Measure troponin I or troponin T on arrival at hospital and repeat 10-12 hours after onset of symptoms. [Based on high quality evidence from meta-analyses in two systematic reviews, 12 cohort studies, and health economic modelling of cost effectiveness] Interpretation of troponin concentrations should take into account the clinical presentation, time of onset of symptoms, and the findings on resting ECG. [Based on the experience and opinion of the GDG]

    • In people with relevant new ST-T wave ECG changes follow appropriate guidance4 or local protocols for ST elevation myocardial infarction until a firm diagnosis is reached.[Based on the experience and opinion of the GDG]

    • Suspect an acute coronary syndrome if other changes, such as Q waves and T wave changes, are seen on ECG, even if no ST segment changes are seen. [Based on high quality evidence from meta-analyses in three systematic reviews]

    • Do not exclude an acute coronary syndrome if the resting ECG is normal. [Based on the experience and opinion of the GDG]

    • When the cause of chest pain is uncertain, continue to monitor clinical and ECG parameters until a firm diagnosis is made. [Based on the experience and opinion of the GDG]

    Making a diagnosis

    • Diagnose acute myocardial infarction according to the universal definition of myocardial infarction,5 and follow appropriate guidance when the diagnosis is made4 or local protocols for ST elevation myocardial infarction. (A summary of the universal definition of myocardial infarction is available at the end of this article, in the further information box.) [Based on the experience and opinion of the GDG]

    • If troponin concentrations are raised, reassess to exclude other causes (such as myocarditis, aortic dissection, or pulmonary embolism) before confirming an acute coronary syndrome. [Based on the experience and opinion of the GDG]

    • Reassess people without raised troponin concentrations who have no changes on resting ECG. If myocardial ischaemia is suspected, follow recommendations on stable chest pain, using clinical judgment to decide on the timing of further diagnostic investigations. [Based on the experience and opinion of the GDG]

    Stable chest pain and suspected angina

    Clinical assessment

    • Determine the age and sex of the person, characteristics of the chest pain, any history of coronary artery disease or other vascular disease, and cardiovascular risk factors. Carry out a physical examination, including identification of non-coronary causes of angina. [Based on high quality evidence from meta-analyses in one systematic review and seven cohort studies] Do not assess symptoms differently in men and women [Based on moderate quality evidence from three cohort studies] and different ethnic groups. [Based on moderate quality evidence from one large cohort study]

    Diagnosis based on clinical assessment

    • Use clinical assessment and the typicality of the features of anginal pain to estimate the likelihood of coronary artery disease (table 2). [Based on moderate quality evidence from one large cohort study]

    • Further diagnostic investigation is unnecessary for typical angina pain if the estimated likelihood of coronary artery disease is greater than 90%. Manage as angina. [Based on the opinion and experience of the GDG]

    • If the estimated likelihood of coronary artery disease is less than 10% first consider causes other than angina. [Based on the opinion and experience of the GDG]

    • Exclude a diagnosis of angina if pain is non-anginal unless suspicion is raised on the basis of other aspects of the assessment. [Based on the opinion and experience of the GDG]

    Table 2

     Percentage* of people estimated to have coronary artery disease according to typicality† of symptoms, age, sex, and risk factors6

    View this table:

    Diagnosis based on clinical assessment and investigations

    • If angina cannot be diagnosed or excluded on the basis of the clinical assessment alone, take a resting 12 lead ECG. Pathological Q waves, left bundle branch block, ST segment abnormalities, and T wave abnormalities may indicate ischaemia or previous myocardial infarction. [Based on high quality evidence of meta-analyses in two systematic reviews]

    • Do not rule out a diagnosis of angina on the basis of a normal resting ECG. [Based on the opinion and experience of the GDG]

    • Take the clinical assessment and the resting ECG into account when estimating the likelihood of coronary artery disease (table 2). Arrange further diagnostic testing as indicated in the box. [Based on high quality evidence from meta-analyses in 10 systematic reviews, 10 cohort studies, and health economic modelling of cost effectiveness]

    • Offer invasive coronary angiography when the results of non-invasive functional imaging are inconclusive. [Based on the opinion and experience of the GDG]

    • Offer non-invasive functional imaging for myocardial ischaemia if invasive coronary angiography or 64 slice (or above) computed tomography coronary angiography has shown coronary artery disease of uncertain functional relevance. [Based on the opinion and experience of the GDG]

    • Offer non-invasive functional testing for people with known coronary artery disease in whom angina cannot be diagnosed or excluded on the basis of clinical assessment alone. [Based on the opinion and experience of the GDG]

    • Do not use magnetic resonance coronary angiography for diagnosing angina. [Based on high quality evidence from meta-analyses in one systematic review]

    • Do not use exercise ECG to diagnose or exclude angina for people without known coronary artery disease. [Based on moderate quality evidence from meta-analyses in one systematic review]

    • Offer information about the risks associated with any radiation exposure during diagnostic testing. [Based on the opinion and experience of the GDG]

    Further diagnostic testing after initial assessment

    Estimated 61-90% likelihood of coronary artery disease
    • Offer invasive coronary angiography as the first line diagnostic investigation if coronary revascularisation is being considered and this test is clinically appropriate and acceptable. If not, offer non-invasive functional imaging

    • [Based on high quality evidence from meta-analyses in one systematic review and health economic modelling of cost effectiveness]

    Estimated 30-60% likelihood of coronary artery disease
    • Offer functional imaging for myocardial ischaemia as the first line diagnostic investigation using:

    • Myocardial perfusion scintigraphy with single photon emission computed tomography

    • Stress echocardiography

    • First pass contrast enhanced magnetic resonance perfusion

    • Magnetic resonance imaging for stress induced wall motion abnormalities

    Estimated 10-29% likelihood of coronary artery disease
    • Offer computed tomography calcium scoring as the first line diagnostic investigation.

      • If the calcium score is zero, consider other causes of chest pain

      • If the score is 1-400, offer 64 slice (or above) computed tomography coronary angiography

      • If the score is >400, offer invasive coronary angiography. If this is not clinically appropriate or acceptable to the patient and revascularisation is not being considered, offer non-invasive functional imaging

    • [Based on high quality evidence from meta-analyses in five systematic reviews, 10 cohort studies, and health economic modelling of cost effectiveness]

    Making a diagnosis after investigations

    Confirm a diagnosis of angina if one or both of the following are true:

    • Significant coronary artery disease is found during invasive or 64 slice (or more) computed tomography coronary angiography

    • Reversible myocardial ischaemia is found during non-invasive functional imaging.

    [Based on high quality evidence from meta-analyses in 10 systematic reviews and health economic modelling of cost effectiveness]

    Overcoming barriers

    This guideline will enhance the understanding of the clinical assessment and investigation of patients with suspected acute coronary syndrome. Healthcare professionals should particularly note the recommendations for the urgency of referral for hospital assessment and the timing of diagnostic testing and ensure these can be implemented. In patients with suspected stable angina, the guideline emphasises the importance of a detailed clinical history to inform an initial triage of whether pain might be cardiac in origin, and mechanisms should be in place to ensure that this is accurately recorded. In patients with non-anginal pain, further diagnostic testing is not generally recommended. In patients with symptoms of typical or atypical angina who require further diagnostic testing, the estimated likelihood of coronary artery disease will determine which tests to use. Healthcare providers should ensure appropriate and timely access to high quality diagnostic testing and interpretation and have systems in place to audit their use.

    Further information on the guidance

    What’s new?

    This guideline has two diagnostic pathways, one for patients with acute chest pain and suspected acute coronary syndrome, and one for patients with intermittent chest pain suspected to be stable angina.

    The guideline has emphasised that patients presenting with acute chest pain that might be caused by an acute coronary syndrome need further investigation with ECG(s) and troponin measurements. In the absence of an alternative diagnosis that can definitely explain the symptoms, the diagnosis cannot be ruled out from the history alone. Recording a 12 lead ECG in patients with suspected acute coronary syndrome is essential to early diagnosis, and if this is done in the community setting the guideline recommends the results should be sent to hospital, but not at the expense of delaying transfer to hospital. For many hospital departments, measuring troponin concentrations at baseline and again at 10-12 hours after the onset of symptoms will be a change to the current practice of making a single measurement. Troponin concentrations should be interpreted in conjunction with symptoms and findings of the resting 12 lead ECG, and the guideline has recommended using the universal definition of myocardial infarction to make a diagnosis of acute myocardial infarction.5

    Currently, symptoms of acute or stable chest pain may be assessed and interpreted differently for women and men and in different ethnic groups, but the guideline recommends that this should not be the case.

    The recommendations for administering oxygen therapy to patients with acute chest pain are very different from current practice and are consistent with the recommendations of the British Thoracic Society.3 Oxygen therapy should not be given routinely to people with acute chest pain, oxygen saturation should be monitored using pulse oximetry, and supplemental oxygen should be offered only if hypoxia is present, with a lower target in those at risk of hypercapnic respiratory failure, pending the results of arterial blood gas analysis.

    The second pathway in this guideline deals with diagnosis in patients with intermittent chest pain, and it is important to realise that the recommendations are aimed at making a diagnosis of angina, not at screening for coronary artery disease. The guideline emphasises the importance of the initial clinical assessment to determine the typicality of symptoms using the Diamond and Forrester criteria for typical angina, atypical angina, and non-anginal pain. The guideline further stratifies patients by age, sex, cardiovascular risk factors, and any changes on resting 12 lead ECG to estimate the likelihood of coronary artery disease and inform the need for further diagnostic testing. Further diagnostic testing is not needed in patients with non-anginal pain, unless clinical suspicion is raised by other aspects of the history. A diagnosis may be reached by clinical assessment alone, or clinical assessment plus diagnostic testing. Diagnostic testing may use anatomical testing to diagnose coronary artery luminal narrowing, functional testing to diagnose myocardial ischaemia, or both. Recommendations for use of a first line anatomical or functional test are based on the initial clinical assessment of the estimated likelihood of coronary artery disease.

    A change in current practice when using computed tomography scanning is that a calcium score should be performed initially and the results used to determine the need for further diagnostic testing and the method that should be used. This is specifically aimed at minimising exposure to radiation. No further testing is needed if the calcium score is zero because this rules out clinically relevant obstructive coronary artery disease with a high degree of accuracy in patients with stable symptoms. The guideline recommends proceeding to computed tomography coronary angiography when the calcium score is 1-400 and to invasive coronary angiography when the calcium score is greater than 400.

    An important change to current practice is that exercise ECG testing is not recommended for patients with no established history of coronary artery disease, because it has poor diagnostic accuracy and investigative strategies using other modalities are more cost effective. Patients with established coronary artery disease and chest pain suspected to be caused by myocardial ischaemia should be referred for non-invasive functional testing, and functional imaging or exercise ECG may be considered in these patients.

    Methodology

    The guideline was developed according to NICE guideline methodology (www.nice.org.uk/aboutnice/howwework/developingniceclinicalguidelines/clinicalguidelinedevelopmentmethods/theguidelinesmanual2007/the_guidelines_manual_2007.jsp). The collaborating centre convened a development group of clinicians and patient representatives to oversee the work and help develop the recommendations. The group conducted an extensive systematic review of the clinical and economic literature and assessed the quality of this literature. The guideline went through an external consultation with stakeholders. The development group assessed the comments, reanalysed the data where necessary, and modified the guideline.

    NICE has produced four different versions of the guideline: a full version; a quick reference guide; a version known as the “NICE guideline” that summarises the recommendations; and a version for patients and the public. All these versions are available from the NICE website (www.nice.org.uk/guidance/CG95).

    Areas of future research
    • •The use of telephone advice in people with chest pain

    • •The clinical effectiveness and cost effectiveness of newly developed, highly sensitive troponin assays and other new cardiac biomarkers in people with acute chest pain who are at low, medium, and high risk of acute coronary syndrome

    • •The cost effectiveness of multislice computed tomography coronary angiography for ruling out obstructive coronary artery disease in people with troponin negative acute coronary syndromes

    • •The clinical effectiveness and cost effectiveness of multislice computed tomography coronary angiography versus functional testing in the diagnosis of angina in people with stable chest pain who have a moderate (30-60%) pretest likelihood of coronary artery disease

    • •To establish a national registry for people undergoing initial assessment for stable angina

    • •To establish the most effective way to provide information about diagnostic tests and the likely outcomes, risks, and benefits, with and without treatment, for particular groups of people defined by age, ethnicity, and sex

    Myocardial infarction5

    The universal definition of myocardial infarction is the detection of a rise or fall (or both) of cardiac biomarkers (preferably troponin), with at least one value above the 99th centile of the upper reference limit, together with evidence of myocardial ischaemia (at least one of the following):

    • •Symptoms of ischaemia

    • •Electrocardiographic changes indicative of new ischaemia (new ST-T changes or new left branch bundle block)

    • •Development of pathological Q wave changes in the electrocardiogram

    • •Imaging evidence of new loss of viable myocardium or new abnormality of regional wall motion

    The clinical classification of myocardial infarction includes:

    • •Type 1: spontaneous myocardial infarction related to ischaemia as a result of a primary coronary event, such as plaque erosion or rupture, fissuring, or dissection

    • •Type 2: myocardial infarction secondary to ischaemia as a result of increased oxygen demand or decreased supply—for example, coronary spasm, coronary embolism, anaemia, arrhythmias, hypertension, or hypotension

    Notes

    Cite this as: BMJ 2010;340:c1118

    Footnotes

    • This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.

    • The members of the guideline panel are Adam Timmis (chair), Jane Skinner (clinical adviser), Philip Adams, John Ashcroft, Neill Calvert, Liz Clark, Angela Cooper, Marian Cotterell, Richard Coulden, Harry Hemingway, David Hill, Cathryn James, Heather Jarman, Jason Kendall, Peter Lewis, Kiran Patel, Laura Sawyer, Liam Smeeth, Katrina Sparrow, John Taylor, and Nancy Turnbull. The co-opted members of the guideline panel are Paul Collinson, Dorothy Frizelle, Steve Goodacre, Marcus Hardbord, and Helen Williams.

    • Contributors: AC, AT, and JS contributed to a first draft that followed the template agreed by the BMJ and NICE and they shared in the subsequent editing. AC is guarantor.

    • Funding: The National Collaborating Guideline Centre for Acute and Chronic Conditions was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary.

    • Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that: (1) AC, AT, and JS have support from NICE for work on guideline development: AC works in the National Collaborating Guideline Centre for Acute and Chronic Conditions funded by NICE; JS receives travel expenses to attend guideline development group and other relevant meetings and payment to her NHS trust to fund her time as clinical adviser for the guideline; AT has support from an NIHR biomedical research unit grant to fund the cardiovascular imaging department; (2) AC, AT, and JS have had no relationships with companies that might have an interest in the submitted work in the previous three years; (3) their spouses, partners, or children have no financial relationships that may be relevant to the submitted work; and (4) they have no non-financial interests that may be relevant to the submitted work.

    • Provenance and peer review: Commissioned; not externally reviewed.

    References