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Guideline Summary
Guideline Title
Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin.
Bibliographic Source(s)
National Clinical Guideline Centre for Acute and Chronic Conditions. Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. London (UK): National Institute for Health and Clinical Excellence (NICE); 2010 Mar. 52 p. (Clinical guideline; no. 95). 
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)
  • Chest pain/discomfort, including coronary artery disease (CAD) and non-cardiac causes
  • Acute coronary syndrome (ACS)

Note: This guideline does not cover the diagnosis and management of chest pain that is unrelated to the heart (for example, traumatic chest wall injury, herpes zoster infection) when myocardial ischaemia has been excluded. The guideline also recognises that in people with a prior diagnosis of coronary artery disease, chest pain or discomfort is not necessarily cardiac.

Guideline Category
Diagnosis
Evaluation
Management
Risk Assessment
Clinical Specialty
Cardiology
Critical Care
Emergency Medicine
Family Practice
Internal Medicine
Preventive Medicine
Intended Users
Advanced Practice Nurses
Emergency Medical Technicians/Paramedics
Physician Assistants
Physicians
Guideline Objective(s)
  • To offer best practice advice on the care of people who present with recent chest pain or discomfort of suspected cardiac origin
  • To provide information on how to determine whether myocardial ischaemia is the cause of the chest pain and how to manage the chest pain while people are being assessed and investigated
Target Population

Adults who have recent onset chest pain or discomfort of suspected cardiac origin, with or without a prior history and/or diagnosis of cardiovascular disease

Interventions and Practices Considered

Evaluation/Diagnosis/Management

  1. Initial assessment and referral to hospital
    • Communication and informed discussion of treatment options
    • Cardiovascular risk factor assessment (such as family history, age and gender)
  2. Resting 12-lead electrocardiogram (ECG)
  3. Immediate management of acute coronary syndrome (ACS)
    • Anti-platelet therapy
    • Oxygen
    • Pain relief
  4. Use of biochemical markers for diagnosis of ACS and myocardial infarction (MI)
  5. Diagnostic tests, including
    • Chest x-ray
    • Blood tests
    • Invasive coronary angiography
    • Non-invasive functional imaging
    • Computed tomography (CT) calcium scoring
    • Myocardial perfusion scintigraphy (MPS) with single photon emission computed tomography (SPECT)
Major Outcomes Considered
  • Sensitivity and specificity of diagnostic tests and approaches
  • Mortality
  • Acute coronary syndrome 
  • Coronary artery disease
  • Cost

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Clinical Guideline Centre for Acute and Chronic Conditions (NCGCACC) on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

Developing Key Clinical Questions (KCQs)

The first step in the development of the guideline was to refine the guideline scope into a series of key clinical questions (KCQs). These KCQs formed the starting point for the subsequent review and as a guide to facilitate the development of recommendations by the Guideline Development Group (GDG).

The KCQs were developed by the GDG and with assistance from the methodology team. The KCQs were refined into specific evidence-based questions (EBQs) specifying interventions to search and outcomes to be searched for by the methodology team and these EBQs formed the basis of the literature searching, appraisal and synthesis.

The total list of KCQs identified is listed in Appendix C1 in the full version of the original guideline document. The development team, in liaison with the GDG, identified those KCQs where a full literature search and critical appraisal were essential.

Literature Search Strategy

Systematic literature searches are undertaken to identify published evidence to answer the clinical questions identified by the methodology team and the Guideline Development Committee (GDG). The information scientist developed search strategies for each question, with guidance from the GDG, using relevant MeSH (medical subject headings) or indexing terms, and free text terms. Searches were conducted between May 2007 and November 2008. Update searches for all questions were carried out in April 2009 to identify any recently published evidence. Full details of the sources and databases searched and the strategies are available in Appendix C2 in the full version of the original guideline document.

An initial scoping search for published guidelines, systematic reviews, economic evaluations and ongoing research was carried out on the following databases or websites: National Library for Health (NLH) Guidelines Finder, National Guideline Clearinghouse, National Institute for Health and Clinical Excellence (NICE) Guidelines, Scottish Intercollegiate Guidelines Network (SIGN), Canadian Medical Association (CMA) Infobase (Canadian guidelines), National Health and Medical Research Council (NHMRC) Clinical Practice Guidelines (Australian Guidelines), New Zealand Guidelines Group, Guidelines International Network (GIN), Organising Medical Networked Information (OMNI), Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effectiveness (DARE) and Heath Technology Assessment Database (HTA), National Health Service (NHS) Economic Evaluations Database (NHSEED), Turning Research into Practice (TRIP), Health Evidence Bulletin Wales, British Medical Journal (BMJ) Clinical Evidence, Department of Health (DH) Data, and King's Fund.

For each clinical question the following bibliographic databases were searched from their inception to the latest date available: Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effectiveness (DARE), Health Technology Database (HTA), MEDLINE, EMBASE, CINAHL, and CENTRAL (Cochrane Controlled Trials Register). When appropriate to the question PsycINFO and Allied and Complementary Medicine Database (AMED) were also searched.

The search strategies were developed in MEDLINE and then adapted for searching in other bibliographic databases. Methodological search filters designed to limit searches to systematic reviews or randomised controlled trials were used. These were developed by the Centre for Reviews and Dissemination (CRD) and The Cochrane Collaboration. For all other questions, no restriction was placed on study design.

The economic literature was identified by conducting searches in National Health Service Economic Evaluations Database (NHSEED) and in MEDLINE, EMBASE and CINAHL using an economics search strategy developed by ScHARR at the University of Sheffield.

Databases of the results of the searches for each question or topic area were created using the bibliographic management software Reference Manager.

Chest Pain Search Strategy

The strategies were developed for use on the Dialog DataStar and OVID web interfaces. For clarification, access to Dialog DataStar was discontinued during the time the guideline was in production, hence the change to OVID. The following databases were searched: Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effectiveness (DARE), Health Technology Assessment Database (HTA), MEDLINE, EMBASE, CENTRAL, and CINAHL. Where appropriate to the question AMED and PsycINFO were also searched. All searches were rerun during March 2009.

The Economic literature was searched using an adapted economic filter developed by the Centre for Reviews and Dissemination (CRD) for Medline and EMBASE. The following were searched: NHS Economic Evaluations Database (NHSEED), MEDLINE, and EMBASE.

The strategies shown are those for MEDLINE using either the Dialog DataStar or OVID interfaces unless otherwise stated. These were then adapted for use on other databases as necessary. Copies of all the search strategies are available on request from the National Clinical Guideline Centre.

Devising a strategy to encompass the wide population included in this guideline proved challenging. A balance had to be achieved in formulating a strategy precise enough to capture the relevant papers amongst a very large literature base, but also sensitive enough to ensure relevant papers were not missed. As a consequence, the strategy was adapted during the development process of the guideline. Due to time constraints it was not possible to go back to earlier searches and rerun them using the new population strategy but checks were made when rerunning all the searches before submission of the guideline to ensure relevant papers had not been missed.

Subsequent to the searching, many of the questions were divided in two - 'Acute Chest Pain' and 'Stable Chest Pain' and papers allocated to each by the reviewer. In addition, some questions were consolidated, for example those for investigations.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

Level Source of Evidence
1++ High-quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias.
1+ Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias.
1– Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias.
2++ High-quality systematic reviews of case-control or cohort studies.

High-quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal.
2+ Well-conducted case-control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal.
2– Case-control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the relationship is not causal.
3 Non-analytic studies (for example case reports, case series).
4 Expert opinion, formal consensus.
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Clinical Guideline Centre for Acute and Chronic Conditions (NCGCACC) on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

Identifying the Evidence

After the search of titles and abstracts was undertaken, full papers were obtained if they appeared to address the key clinical question (KCQ). The highest level of evidence was sought. Systematic reviews were initially selected. Where systematic reviews had recently been published, the identification of further studies was not done. Where systematic reviews were not available, diagnostic cohort studies were selected for intervention KCQs, and cohort studies were selected for other KCQs. Surveys were not selected. Expert consensus was used when no studies were available that addressed the KCQ. Following a critical review of the full text paper, articles not relevant to the subject in question were excluded. Cohort and diagnostic studies were excluded if they were conducted on an inappropriate patient population. Diagnostic studies were excluded if the test being evaluated was not compared with a reference standard (that would confirm or refute the diagnosis), and if the test and the reference standard were not evaluated in all patients in the study. Diagnostic studies that did not provide test accuracy statistics (for example sensitivity, specificity) were also excluded.

Critical Appraisal of the Evidence

From the papers retrieved, the Senior Health Service Research Fellow (SHSRF) synthesized the evidence for each question or questions into a narrative summary. These form the basis of this guideline. Each study was critically appraised using the Institute's criteria for quality assessment and the information extracted for included studies is given in Appendix D in the full version of the original guideline document. Background papers, for example those used to set the clinical scene in the narrative summaries, were referenced but not extracted.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Clinical Guideline Centre for Acute and Chronic Conditions (NCGCACC) on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

Developing Key Clinical Questions (KCQs)

The first step in the development of the guideline was to refine the guideline scope into a series of key clinical questions (KCQs). These KCQs formed the starting point for the subsequent review and as a guide to facilitate the development of recommendations by the Guideline Development Group (GDG).

The KCQs were developed by the GDG and with assistance from the methodology team. The KCQs were refined into specific evidence-based questions (EBQs) specifying interventions to search and outcomes to be searched for by the methodology team and these EBQs formed the basis of the literature searching, appraisal and synthesis. The total list of KCQs identified is listed in Appendix C1 (in the full version of the original guideline document). The development team, in liaison with the GDG, identified those KCQs where a full literature search and critical appraisal were essential.

Forming Recommendations

In preparation for each meeting, the narrative and extractions for the questions being discussed were made available to the GDG one week before the scheduled GDG meeting. These documents were available on a closed intranet site and sent by post to those members who requested it.

GDG members were expected to have read the narratives and extractions before attending each meeting. The GDG discussed the evidence at the meeting and agreed evidence statements and recommendations. Any changes were made to the electronic version of the text on a laptop and projected onto a screen until the GDG were satisfied with these.

Recommendations were also documented in a care pathway which was reviewed regularly by the GDG.

All work from the meetings was posted on the closed intranet site following the meeting as a matter of record and for referral by the GDG members.

Areas Without Evidence and Consensus Methodology

The table of clinical questions in Appendix C1 (in the full version of the original guideline document) indicates which questions were searched.

In cases where evidence was sparse, the GDG derived the recommendations via informal consensus methods, using extrapolated evidence where appropriate. All details of how the recommendations were derived can be seen in the 'Evidence to Recommendations' section of each of the chapters.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

Health Economic Evidence Reviews

A broad search of health economics literature was developed based on the original scoping search for the Guideline. The economic literature was identified by conducting searches in National Health Service (NHS) Economic Evaluations Database (NHSEED) and also in MEDLINE, EMBASE and CINAHL using an economics search strategy developed by ScHARR at the University of Sheffield. Towards the end of the development of the Guideline, update searches were conducted to search for studies which had been published during the development phase of the Guideline. Databases of the results of the searches for each key clinical question (KCQ) or topic area were created using the bibliographic management software Reference Manager™.

Identified titles and abstracts from the economic searches were reviewed by a health economist and full papers obtained as appropriate. Retrieved papers where then reviewed by a health economist, and considered for inclusion in the Guideline. No formal inclusion or exclusion criterion was applied a priori. Each paper was considered on its own merit and in the context of availability of relevant published economic evaluations to inform the KCQs. All valid incremental cost-utility (quality-adjusted life year [QALY]) analyses (including cost-consequence analyses where the incremental analyses could be calculated from the available study data), taking a National Health Service (NHS) costing perspective, were included for all KCQs. In the absence of NHS based cost-utility analyses, incremental cost effectiveness analyses using alternative outcome measures (e.g., the proportion of patients correctly diagnosed), were considered. For KCQs designated as high priority for economic evaluation (primarily investigations for diagnosis of stable and acute chest pain), if no United Kingdom (UK) based economic evaluations were found in the literature, then non-UK economic evaluations were considered for inclusion, if it was felt that they would inform the Guideline Development Group's (GDG's) consideration of the cost-effectiveness for the KCQ under consideration (e.g. where there was dominance which was likely to be replicated in a UK based analysis).

The main reasons for exclusion were that the published study was not an economic evaluation, or that the study population did not meet the inclusion criteria for the review of clinical evidence, as set out in the NICE scope document and as agreed by the GDG. Reasons for exclusion for all requested papers were systematically recorded by the health economist using the Reference Manager database. A general descriptive overview of the included studies, their quality, and conclusions was presented and summarized in the form of a narrative review (see also Appendix E in the full version of the original guideline document for the full extractions and reasons for exclusion).

Cost-effectiveness Modeling

Having reviewed the health economics literature for this guideline, some de novo economic modelling was undertaken to supplement the available published economic analyses. A summary of the methods is provided here with details presented in Appendix F in the full version of the original guideline document.

Firstly, with the cooperation of the developers of the model presented in the Mowatt 2008 Heath Technology Assessment Database (HTA), the guideline developers replicated their short-term model for diagnosis of coronary artery disease (CAD). Outputs from the replicated model include short term costs of diagnosis, the 2*2 true, false, positive, negative matrix, and the incremental cost per correctly diagnosed patient. Only the short term cost of diagnosis was previously available from the data presented in the HTA. Both the original analysis presented in the HTA, and the new analysis produced using the replicated model found heavily in favour of 64-slice computed tomography (CT) coronary angiography (e.g., dominance over myocardial perfusion scintigraphy [MPS] with single-photon emission computed tomographic [SPECT]). The GDG, however, had reservations about the existing model, primarily:

  • Its relevance for diagnosis of angina (as opposed to coronary artery stenosis assessed by invasive coronary angiography)
  • The high sensitivity of 64-slice CT coronary angiography
  • Risk of radiation from 64-slice CT coronary angiography

The latter two reservations were addressed by making revisions to model input assumptions, and by the addition of two new treatment arms respectively. The two new treatment arms explore the health economic impact of using calcium scoring as a pre-cursor to full CT scanning using 64-slice CT. That is, first line testing in the new treatment arm would be by calcium scoring. Patients testing positive or uncertain would then proceed to second line testing using full 64-slice CT coronary angiography. Patients with a negative calcium score would have no further testing, as per the existing model protocol. The difference in the two new treatment arms is inclusion, or exclusion, of invasive coronary angiography as confirmatory third line test.

Because the GDG believed that there was still a role for functional (as opposed to anatomical) testing in chest pain patient populations with moderate likelihood of CAD, a new economic model was built comparing first line functional testing using stress MPS with SPECT compared to first line anatomical testing using invasive coronary angiography. In a sensitivity analysis, invasive coronary angiography was substituted with 64-slice CT coronary angiography.

The economic evaluations presented in the Mowatt et al HTAs of 2004 and 2008 did build "speculative" longer term cost per QALY Markov models. These models required speculative assumptions to be made about the re-presentations of false-negatives, which of the coronary arteries had significant stenosis, and how these would be treated, as well as the survival and health related quality of life assumptions that would result for treated patients. The results of the longer term model analysis presented in Mowatt 2008 indicated that the difference in QALY outcomes was less than one quarter of one percent. Also, results presented in the MPS HTA of 2004 (tables 39 and 40) indicate that for all but the lowest CAD prevalence populations, the incremental cost-effectiveness ratios (ICERs) of the short term cost per proportion of cases correctly diagnosed and the speculative longer term costs per QALY, have similar values, indicating that the former might be a useful proxy for the latter. Based on the above, and because of the diagnostic scope of this guideline, the incremental economic analysis from our de novo models has been confined to the short term incremental cost per correct diagnosis. The GDG was consulted during the construction and interpretation of the model to ensure that appropriate assumptions, model structure, and data sources were used. The results of the de novo health economic analysis are presented in Chapter 5 (full version of the original guideline document) with further detail of the results and methods presented in Appendix F (of the full version). (See the "Availability of Companion Documents" field.)

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The guideline was validated through two consultations.

  1. The first draft of the guideline (the Full guideline, National Institute for Health and Clinical Excellence [NICE] guideline, and Quick Reference Guide) were consulted with Stakeholders and comments were considered by the Guideline Development Group (GDG)
  2. The final consultation draft of the Full guideline, the NICE guideline, and the Information for the Public were submitted to stakeholders for final comments.

The final draft was submitted to the Guideline Review Panel for review prior to publication.

Recommendations

Major Recommendations

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Clinical Guideline Centre for Acute and Chronic Conditions (NCGCACC) on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

Providing Information for People with Chest Pain

  • 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.
  • Offer people a clear explanation of the possible causes of their symptoms and the uncertainties.
  • Clearly explain the options to people at every stage of investigation. Make joint decisions with them and take account of their preferences:
    • Encourage people to ask questions.
    • Provide repeated opportunities for discussion.
    • Explain test results and the need for any further investigations.
  • 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.

*For example, Unstable angina and NSTEMI (see the National Guideline Clearinghouse [NGC] summary of the National Institute for Health and Clinical Excellence [NICE] clinical guideline Unstable angina and NSTEMI), Anxiety External Web Site Policy (NICE clinical guideline 22) and Dyspepsia External Web Site Policy (NICE clinical guideline 17).

People Presenting with Acute Chest Pain

This section of the guideline covers the assessment and diagnosis of people with recent acute chest pain or discomfort, suspected to be caused by an acute coronary syndrome (ACS). The term ACS covers a range of conditions including unstable angina, ST-segment-elevation myocardial infarction (STEMI) and non-ST-segment-elevation myocardial infarction (NSTEMI).

The guideline addresses assessment and diagnosis irrespective of setting, because people present in different ways. Please note that Unstable angina and NSTEMI (NICE clinical guideline 94) (see the NGC summary of the NICE clinical guideline) covers the early management of these conditions once a firm diagnosis has been made and before discharge from hospital.

Initial Assessment and Referral to Hospital

  • Check immediately whether people currently have chest pain. If they are pain free, check when their last episode of pain was, particularly if they have had pain in the last 12 hours.
  • Determine whether the chest pain may be cardiac and therefore whether this guideline is relevant, by considering:
    • The history of the chest pain
    • The presence of cardiovascular risk factors
    • History of ischaemic heart disease and any previous treatment
    • Previous investigations for chest pain
  • Initially assess people for any of the following symptoms, which may indicate an ACS:
    • 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 haemodynamic 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
  • Do not use people's response to glyceryl trinitrate (GTN) to make a diagnosis.
  • Do not assess symptoms of an ACS differently in men and women. Not all people with an ACS present with central chest pain as the predominant feature.
  • 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.
  • Refer people to hospital as an emergency if an ACS is suspected and:
    • They currently have chest pain or
    • They are currently pain free, but had chest pain in the last 12 hours, and a resting 12-lead electrocardiography (ECG) is abnormal or not available.
  • If an ACS is suspected and there are no reasons for emergency referral, refer people for urgent same-day assessment if:
    • They had chest pain in the last 12 hours, but are now pain free with a normal resting 12-lead ECG or
    • The last episode of pain was 12–72 hours ago.
  • Refer people for assessment in hospital if an ACS is suspected and:
    • The pain has resolved and
    • There are signs of complications such as pulmonary oedema

    Use clinical judgment to decide whether referral should be as an emergency or urgent same-day assessment.

  • If a recent ACS is suspected in people whose last episode of chest pain was more than 72 hours ago and who have no complications such as pulmonary oedema:
    • Carry out a detailed clinical assessment
    • Confirm the diagnosis by resting 12-lead ECG and blood troponin level
    • Take into account the length of time since the suspected ACS when interpreting the troponin level.

    Use clinical judgment to decide whether referral is necessary and how urgent this should be.

  • Refer people to hospital as an emergency if they have a recent (confirmed or suspected) ACS and develop further chest pain.
  • When an ACS is suspected, start management immediately in the order appropriate to the circumstances (see section "Immediate Management of a Suspected Acute Coronary Syndrome" below) and take a resting 12-lead ECG (see section "Resting 12-lead ECG" below). Take the ECG as soon as possible, but do not delay transfer to hospital.
  • If an ACS is not suspected, consider other causes of the chest pain, some of which may be life-threatening (see recommendations below).

Resting 12-Lead ECG

  • Take a resting 12-lead 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.
  • Follow local protocols for people with a resting 12-lead ECG showing regional ST-segment elevation or presumed new left bundle branch block (LBBB) consistent with an acute STEMI until a firm diagnosis is made. Continue to monitor.
  • Follow Unstable angina and NSTEMI (see the National Guideline Clearinghouse [NGC] summary of the NICE clinical guideline) for people with a resting 12-lead ECG showing regional ST-segment depression or deep T wave inversion suggestive of a NSTEMI or unstable angina until a firm diagnosis is made. Continue to monitor.
  • Even in the absence of ST-segment changes, have an increased suspicion of an ACS if there are other changes in the resting 12-lead ECG, specifically Q waves and T wave changes. Consider following Unstable angina and NSTEMI (see the NGC summary of the NICE clinical guideline) if these conditions are likely. Continue to monitor.
  • Do not exclude an ACS when people have a normal resting 12-lead ECG.
  • If a diagnosis of ACS is in doubt, consider:
    • Taking serial resting 12-lead ECGs
    • Reviewing previous resting 12-lead ECGs
    • Recording additional ECG leads

    Use clinical judgment to decide how often this should be done. Note that the results may not be conclusive.

  • Obtain a review of resting 12-lead ECGs by a healthcare professional qualified to interpret them as well as taking into account automated interpretation.
  • If clinical assessment and a resting 12-lead ECG make a diagnosis of ACS less likely, consider other acute conditions. First consider those that are life threatening such as pulmonary embolism, aortic dissection or pneumonia. Continue to monitor.

Immediate Management of a Suspected Acute Coronary Syndrome

Management of ACS should start as soon as it is suspected, but should not delay transfer to hospital. The recommendations in this section should be carried out in the order appropriate to the circumstances.

  • Offer pain relief as soon as possible. This may be achieved with glyceryl trinitrate (GTN) (sublingual or buccal), but offer intravenous opioids such as morphine, particularly if an acute myocardial infarction (MI) is suspected.
  • Offer people a single loading dose of 300 mg aspirin as soon as possible unless there is clear evidence that they are allergic to it. If aspirin is given before arrival at hospital, send a written record that it has been given with the person. Only offer other antiplatelet agents in hospital. Follow appropriate guidance (see the NGC summary of the NICE clinical guideline Unstable angina and NSTEMI) or local protocols for STEMI).
  • 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 (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94–98%
    • People with 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.
  • Monitor people with acute chest pain, using clinical judgment to decide how often this should be done, until a firm diagnosis is made. This should include:
    • Exacerbations of pain and/or other symptoms
    • Pulse and blood pressure
    • Heart rhythm
    • Oxygen saturation by pulse oximetry
    • Repeated resting 12-lead ECGs and
    • Checking pain relief is effective
  • Manage other therapeutic interventions using appropriate guidance (see the NGC summary of the NICE clinical guideline Unstable angina and NSTEMI) or local protocols for STEMI).

Assessment in Hospital for People with a Suspected Acute Coronary Syndrome

  • Take a resting 12-lead ECG and a blood sample for troponin I or T measurement on arrival in hospital.
  • Carry out a physical examination to determine:
    • Haemodynamic status
    • Signs of complications, for example pulmonary oedema
    • Cardiogenic shock and
    • Signs of non-coronary causes of acute chest pain, such as aortic dissection
  • Take a detailed clinical history unless a STEMI is confirmed from the resting 12-lead ECG (that is, regional ST-segment elevation or presumed new left bundle branch block [LBBB]). Record:
    • The characteristics of the pain
    • Other associated symptoms
    • Any history of cardiovascular disease
    • Any cardiovascular risk factors and
    • Details of previous investigations or treatments for similar symptoms of chest pain

Use of Biochemical Markers for Diagnosis of an Acute Coronary Syndrome

  • Take a blood sample for troponin I or T measurement on initial assessment in hospital. These are the preferred biochemical markers to diagnose acute MI.
  • Take a second blood sample for troponin I or T measurement 10–12 hours after the onset of symptoms.
  • Do not use biochemical markers such as natriuretic peptides and high sensitivity C-reactive protein to diagnose an ACS.
  • Do not use biochemical markers of myocardial ischaemia (such as ischaemia-modified albumin) as opposed to markers of necrosis when assessing people with acute chest pain.
  • Take into account the clinical presentation, the time from onset of symptoms and the resting 12-lead ECG findings when interpreting troponin measurements.

Making a Diagnosis

  • When diagnosing MI, use the universal definition of myocardial infarction. This is the detection of rise and/or fall of cardiac biomarkers (preferably troponin) with at least one value above the 99th percentile of the upper reference limit, together with evidence of myocardial ischaemia with at least one of the following:
    • Symptoms of ischaemia
    • ECG changes indicative of new ischaemia (new ST-T changes or new LBBB)
    • Development of pathological Q wave changes in the ECG
    • Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality.**

    ** The Guideline Development Group did not review the evidence for the use of imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in the diagnosis of MI, but recognized that it was included as a criterion in the universal definition of MI. The Guideline Development Group recognized that it could be used, but would not be done routinely when there were symptoms of ischaemia and ECG changes.)

    The clinical classification of MI includes:

    • Type 1: spontaneous MI related to ischaemia due to a primary coronary event such as plaque erosion and/or rupture, fissuring or dissection.
    • Type 2: MI secondary to ischaemia due to either increased oxygen demand or decreased supply, such as coronary spasm, coronary embolism, anaemia, arrhythmias, hypertension, or hypotension.
  • When a raised troponin level is detected in people with a suspected ACS, reassess to exclude other causes for raised troponin (for example, myocarditis, aortic dissection or pulmonary embolism) before confirming the diagnosis of ACS.
  • When a raised troponin level is detected in people with a suspected ACS, follow the appropriate guidance (see the NGC summary of the NICE clinical guideline Unstable angina and NSTEMI or local protocols for STEMI) until a firm diagnosis is made. Continue to monitor.
  • When a diagnosis of ACS is confirmed, follow the appropriate guidance (see the NGC summary of the NICE clinical guideline Unstable angina and NSTEMI or local protocols for STEMI).
  • Reassess people with chest pain without raised troponin levels (determined from appropriately timed samples) and no acute resting 12-lead ECG changes to determine whether their chest pain is likely to be cardiac. If myocardial ischaemia is suspected, follow the recommendations on stable chest pain in this guideline. Use clinical judgment to decide on the timing of any further diagnostic investigations.
  • Consider a chest X-ray to help exclude complications of ACS such as pulmonary oedema, or other diagnoses such as pneumothorax or pneumonia.
  • Only consider early chest computed tomography (CT) to rule out other diagnoses such as pulmonary embolism or aortic dissection, not to diagnose ACS.
  • If an ACS has been excluded at any point in the care pathway, but people have risk factors for cardiovascular disease, follow the appropriate guidance, for example Lipid modification External Web Site Policy (NICE clinical guideline 67), Hypertension External Web Site Policy (NICE clinical guideline 34).

People Presenting with Stable Chest Pain

This section of the guideline addresses the assessment and diagnosis of intermittent stable chest pain in people with suspected stable angina. Angina is usually caused by coronary artery disease (CAD). Making a diagnosis of stable angina caused by CAD in people with chest pain is not always straightforward, and the recommendations aim to guide and support clinical judgment. Clinical assessment alone may be sufficient to confirm or exclude a diagnosis of stable angina, but when there is uncertainty, additional diagnostic testing (functional or anatomical testing) guided by the estimates of likelihood of coronary artery disease in table 1 in the original guideline document is required.

  • Diagnose stable angina based on one of the following:
    • Clinical assessment alone or
    • Clinical assessment plus diagnostic testing (that is, anatomical testing for obstructive CAD and/or functional testing for myocardial ischaemia).

Clinical Assessment

  • Take a detailed clinical history documenting:
    • The age and sex of the person
    • The characteristics of the pain, including its location, radiation, severity, duration and frequency, and factors that provoke and relieve the pain
    • Any associated symptoms, such as breathlessness
    • Any history of angina, MI, coronary revascularization, or other cardiovascular disease and
    • Any cardiovascular risk factors
  • Carry out a physical examination to:
    • Identify risk factors for cardiovascular disease
    • Identify signs of other cardiovascular disease
    • Identify non-coronary causes of angina (for example, severe aortic stenosis, cardiomyopathy) and
    • Exclude other causes of chest pain

Making a Diagnosis Based on Clinical Assessment

  • 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 GTN within about 5 minute

    Use clinical assessment and the typicality of anginal pain features listed below to estimate the likelihood of CAD (see table 1 in the original guideline document):

    • Three of the features above are defined as typical angina.
    • Two of the three features above are defined as atypical angina.
    • One or none of the features above are defined as non-anginal chest pain.
  • Do not define typical and atypical features of anginal chest pain and non-anginal chest pain differently in men and women.
  • Do not define typical and atypical features of anginal chest pain and non-anginal chest pain differently in ethnic groups.
  • Take the following factors, which make a diagnosis of stable angina more likely, into account when estimating people's likelihood of angina:
    • Increasing age
    • Whether the person is male
    • Cardiovascular risk factors including:
      • A history of smoking
      • Diabetes
      • Hypertension
      • Dyslipidaemia
      • Family history of premature CAD
      • Other cardiovascular disease
  • History of established CAD, for example previous MI, coronary revascularisation.
  • If people have features of typical angina based on clinical assessment and their estimated likelihood of CAD is greater than 90% (see table 1 in the original guideline document), further diagnostic investigation is unnecessary. Manage as angina.
  • 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 (see recommendation above). 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 estimated likelihood of CAD is less than 10% (see table 1 in the original guideline document), first consider causes of chest pain other than angina caused by CAD.
  • Consider investigating other causes of angina, such as hypertrophic cardiomyopathy, in people with typical angina-like chest pain and a low likelihood of CAD (estimated at less than 10%).
  • Arrange blood tests to identify conditions which exacerbate angina, such as anaemia, for all people being investigated for stable angina.
  • Only consider chest X-ray if other diagnoses, such as a lung tumour, are suspected.
  • If a diagnosis of stable angina has been excluded at any point in the care pathway, but people have risk factors for cardiovascular disease, follow the appropriate guidance, for example Lipid modification External Web Site Policy (NICE clinical guideline 67), Hypertension External Web Site Policy (NICE clinical guideline 34).
  • For people in whom stable angina cannot be diagnosed or excluded on the basis of the clinical assessment alone, take a resting 12-lead ECG as soon as possible after presentation.
  • Do not rule out a diagnosis of stable angina on the basis of a normal resting 12-lead ECG.
  • A number of changes on a resting 12-lead ECG are consistent with CAD and may indicate ischaemia or previous infarction. These include:
    • Pathological Q waves in particular
    • LBBB
    • ST-segment and T wave abnormalities (for example, flattening or inversion)

    Note that the results may not be conclusive.

    Consider any resting 12-lead ECG changes together with people's clinical history and risk factors.

  • For people with confirmed CAD (for example, previous MI, revascularization, previous angiography) in whom stable angina cannot be diagnosed or excluded based on clinical assessment alone, see recommendation below about functional testing.
  • In people without confirmed CAD, in whom stable angina cannot be diagnosed or excluded based on clinical assessment alone, estimate the likelihood of CAD (see table 1 in the original guideline document). 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.
  • Consider aspirin only if the person's chest pain is likely to be stable angina, until a diagnosis is made. Do not offer additional aspirin if there is clear evidence that people are already taking aspirin regularly or are allergic to it.
  • Follow local protocols for stable angina*** while waiting for the results of investigations if symptoms are typical of stable angina.

***NICE is developing the clinical guideline 'The management of stable angina' (publication expected July 2011).

Diagnostic Testing for People in Whom Stable Angina Cannot be Diagnosed or Excluded by Clinical Assessment Alone

This guideline addresses only the diagnostic value of tests for stable angina. The prognostic value of these tests was not considered.

The Guideline Development Group carefully considered the risk of radiation exposure from diagnostic tests. It discussed that the risk needs to be considered in the context of radiation exposure from everyday life, the substantial intrinsic risk that a person will develop cancer during their lifetime and the potential risk of failing to make an important diagnosis if a particular test is not performed. The commonly accepted estimate of the additional lifetime risk of dying from cancer with 10 millisieverts of radiation is 1 in 2007. 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, in which case the risk of undiagnosed angina outweighs the risk of any potential radiation exposure.

  • Include the typicality of anginal pain features and the estimate of CAD likelihood in all requests for diagnostic investigations and in the person's notes.
  • Use clinical judgment and take into account people's preferences and comorbidities when considering diagnostic testing.
  • Take into account people's risk from radiation exposure when considering which diagnostic test to use.
  • For people with chest pain in whom stable angina cannot be diagnosed or excluded by clinical assessment alone and who have an estimated likelihood of CAD of 61–90%, offer invasive coronary angiography after clinical assessment and a resting 12-lead ECG if:
    • Coronary revascularization is being considered and
    • Invasive coronary angiography is clinically appropriate and acceptable to the person
  • For people with chest pain in whom stable angina cannot be diagnosed or excluded by clinical assessment alone and who have an estimated likelihood of CAD of 61–90%, offer non-invasive functional imaging after clinical assessment and a resting 12-lead ECG if:
    • Coronary revascularization is not being considered or
    • Invasive coronary angiography is not clinically appropriate or acceptable to the person
  • For people with chest pain in whom stable angina cannot be diagnosed or excluded by clinical assessment alone and who have an estimated likelihood of CAD of 30–60%, offer non-invasive functional imaging for myocardial ischaemia. See section below for further guidance on non-invasive functional testing.
  • For people with chest pain in whom stable angina cannot be diagnosed or excluded by clinical assessment alone and who have an estimated likelihood of CAD of 10–29% offer CT calcium scoring. If the calcium score is:
    • Zero, consider other causes of chest pain
    • 1–400, offer 64-slice (or above) CT coronary angiography
    • Greater than 400, offer invasive coronary angiography. If this is not clinically appropriate or acceptable to the person and revascularization is not being considered, offer non-invasive functional imaging. See section below for further guidance on non-invasive functional testing.
  • For people with confirmed CAD (for example, previous MI, revascularization, previous angiography), offer non-invasive functional testing when there is uncertainty about whether chest pain is caused by myocardial ischaemia. See section below for further guidance on non-invasive functional testing. An exercise ECG may be used instead of functional imaging.

Additional Diagnostic Investigations

  • Offer non-invasive functional imaging for myocardial ischaemia if invasive coronary angiography or 64-slice (or above) CT coronary angiography has shown CAD of uncertain functional significance.
  • Offer invasive coronary angiography as a second-line investigation when the results of non-invasive functional imaging are inconclusive.

Use of Non-Invasive Functional Testing for Myocardial Ischaemia

  • When offering non-invasive functional imaging for myocardial ischaemia use:
    • Myocardial perfusion scintigraphy with single photon emission computed tomography (MPS with SPECT) or
    • Stress echocardiography or
    • First-pass contrast-enhanced magnetic resonance (MR) perfusion or
    • MR imaging for stress-induced wall motion abnormalities
  • Take account of locally available technology and expertise, the person and their preferences, and any contraindications when deciding on the imaging method. (This recommendation updates and replaces recommendation 1.1 of Myocardial perfusion scintigraphy for the diagnosis and management of angina and myocardial infarction External Web Site Policy) (NICE technology appraisal guidance 73).
  • 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.
  • Do not use MR coronary angiography for diagnosing stable angina.
  • Do not use exercise ECG to diagnose or exclude stable angina for people without known CAD.

Making a Diagnosis Following Investigations

  • Confirm a diagnosis of stable angina and follow local guidelines for angina*** when:
    • Significant CAD (see box below) is found during invasive or 64-slice (or above) CT coronary angiography and/or
    • Reversible myocardial ischaemia is found during non-invasive functional imaging.

***NICE is developing the clinical guideline 'The management of stable angina' (publication expected July 2011).

Definition of Significant Coronary Artery Disease

Significant coronary artery disease (CAD) found during invasive coronary angiography is ≥70% diameter stenosis of at least one major epicardial artery segment or ≥50% diameter stenosis in the left main coronary artery:

  • Factors intensifying ischaemia

    Such factors allow less severe lesions (for example ≥50%) to produce angina:

    • Reduced oxygen delivery: anaemia, coronary spasm
    • Increased oxygen demand: tachycardia, left ventricular hypertrophy
    • Large mass of ischaemic myocardium: proximally located lesions
    • Longer lesion length
  • Factors reducing ischaemia

    Such factors may render severe lesions (≥70%) asymptomatic:

    • Well developed collateral supply
    • Small mass of ischaemic myocardium: distally located lesions, old infarction in the territory of coronary supply
  • Investigate other causes of chest pain when:
    • Significant CAD (see box above) is not found during invasive coronary angiography or 64-slice (or above) CT coronary angiography and/or
    • Reversible myocardial ischaemia is not found during non-invasive functional imaging or
    • The calcium score is zero.
  • Consider investigating other causes of angina, such as hypertrophic cardiomyopathy or syndrome X, in people with typical angina-like chest pain if investigation excludes flow-limiting disease in the epicardial coronary arteries.  
Clinical Algorithm(s)

Appendix C in the original guideline document includes the following algorithms:

  • Acute chest pain pathway part 1: Initial assessment and referral to hospital for recent acute chest pain of suspected cardiac origin
  • Acute chest pain pathway part 2: Investigation and diagnosis in hospital
  • Stable chest pain pathway part 1: Presentation
  • Stable chest pain pathway part 2: Diagnostic testing for people in whom stable angina cannot be diagnosed or excluded by clinical assessment alone
  • Stable chest pain pathway part 3: Established prior diagnosis of coronary artery disease

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is not specifically stated for each recommendation.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements
  • This guidance represents the view of National Institute for Health and Clinical Excellence (NICE), which was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgment. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, and informed by the summary of product characteristics of any drugs they are considering.
  • Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.
  • This guideline will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.

Implementation of the Guideline

Description of Implementation Strategy

The Healthcare Commission assesses how well National Health Service (NHS) organisations meet core and developmental standards set by the Department of Health in 'Standards for better health' (available from www.dh.gov.uk External Web Site Policy). Implementation of clinical guidelines forms part of the developmental standard D2. Core standard C5 says that NHS organizations should be taken into account national agreed guidance when planning and delivering care.

The National Institute for Health and Clinical Excellence (NICE) has developed tools to help organizations implement this guidance (see www.nice.org.uk/guidance/CG95 External Web Site Policy).

Key Priorities for Implementation

Presentation with Acute Chest Pain

  • 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 (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94–98%
    • People with 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.
  • 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.

Presentation with Stable Chest Pain

  • Diagnose stable angina based on one of the following:
    • Clinical assessment alone or
    • Clinical assessment plus diagnostic testing (that is, anatomical testing for obstructive coronary artery disease [CAD] and/or functional testing for myocardial ischaemia).
  • If people have features of typical angina based on clinical assessment and their estimated likelihood of CAD is greater than 90% (see table 1 in the original guideline document), further diagnostic investigation is unnecessary. Manage as angina.
  • 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).
  • 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 (see table 1 in the original guideline document). 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.
Implementation Tools
Audit Criteria/Indicators
Chart Documentation/Checklists/Forms
Clinical Algorithm
Foreign Language Translations
Patient Resources
Quick Reference Guides/Physician Guides
Resources
Slide Presentation
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
National Clinical Guideline Centre for Acute and Chronic Conditions. Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. London (UK): National Institute for Health and Clinical Excellence (NICE); 2010 Mar. 52 p. (Clinical guideline; no. 95). 
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 Mar
Guideline Developer(s)
National Clinical Guideline Centre for Acute and Chronic Conditions - National Government Agency [Non-U.S.]
Source(s) of Funding

National Institute for Health and Clinical Excellence

Guideline Committee

Guideline Development Group

Composition of Group That Authored the Guideline

Group Members: Professor Adam Timmis (Chair), Professor of Clinical Cardiology, Barts and the London, Queen Mary's School of Medicine and Dentistry, London; Dr Jane Skinner (Clinical Adviser), Consultant Community Cardiologist, Royal Victoria Infirmary, Newcastle Upon Tyne; Dr Philip Adams, Cardiologist Consultant, Royal Victoria Infirmary, Newcastle Upon Tyne; Dr John Ashcroft, General Practitioner, Old Station Surgery, Ilkeston, Derbyshire; Ms Liz Clark, Patient Representative; Dr Richard Coulden, Consultant Cardiothoracic Radiologist, Glenfield Hospital, Leicester; Professor Harry Hemingway, Public Health Physician Epidemiologist, University College London Medical School, London; Mrs Cathryn James, Clinical Pathways Adviser/Emergency Care Practitioner, Yorkshire Ambulance Service Headquarters, Wakefield; Ms Heather Jarman, Consultant Nurse in Emergency Care, St George’s Healthcare NHS Trust, London; Dr Jason Kendall, Consultant in Emergency Medicine, Frenchay Hospital, Bristol; Mr Peter Lewis, Chief Clinical Physiologist, Prince Charles Hospital, Merthyr Tydfil, Wales; Dr Kiran Patel, Consultant Cardiologist and Honorary Senior Lecturer in Cardiovascular Medicine, Sandwell and West Birmingham NHS Trust and University of Birmingham, West Bromwich, West Midlands; Professor Liam Smeeth, Professor of Clinical Epidemiology, London School of Hygiene and Tropical Medicine, London; Mr John Taylor, Patient Representative; Nancy Turnbull, Guideline Lead, National Clinical Guideline Centre for Acute and Chronic Conditions; Dr Angela Cooper, Senior Health Services Research Fellow, National Clinical Guideline Centre for Acute and Chronic Conditions; Katrina Sparrow, Health Services Research Fellow, National Clinical Guideline Centre for Acute and Chronic Conditions; Dr Neill Calvert, Head of Health Economics, National Clinical Guideline Centre for Acute and Chronic Conditions; Laura Sawyer, Health Economist, National Clinical Guideline Centre for Acute and Chronic Conditions; David Hill, Project Manager (until December 2009), National Clinical Guideline Centre for Acute and Chronic Conditions; Marian Cotterell, Information Scientist (until January 2009), National Clinical Guideline Centre for Acute and Chronic Conditions

Financial Disclosures/Conflicts of Interest

In accordance with guidance from National Institute for Health and Clinical Excellence (NICE), all guideline development group (GDG) members interests were recorded on a standard declaration form that covered consultancies, fee-paid work, share-holdings, fellowships, and support from the healthcare industry. Details of these can be seen in Appendix B of the full version of the original guideline document.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the National Institute for Health and Clinical Excellence (NICE) Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. Full guideline and appendices. London (UK): National Institute for Health and Clinical Excellence (NICE); 2010 Mar. 393 p. (Clinical guideline; no. 95). Electronic copies: Available in Portable Document Format (PDF) format from the National Institute for Health and Clinical Excellence (NICE) Web site External Web Site Policy.
  • Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. Quick reference guide. London (UK): National Institute for Health and Clinical Excellence; 2010 Mar. 17 p. (Clinical guideline; no. 95). Electronic copies: Available in Portable Document Format (PDF) from the NICE Web site. External Web Site Policy
  • Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. Audit support. London (UK): National Institute for Health and Clinical Excellence; 2010 Mar. 15 p. (Clinical guideline; no. 95). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. Slide set. Implementing NICE guidance. London (UK): National Institute for Health and Clinical Excellence; 2010. 17 p. (Clinical guideline; no. 95). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. Implementation advice. London (UK): National Institute for Health and Clinical Excellence; 2010. 24 p. (Clinical guideline; no. 95). Electronic copies: Available in Portable Document Format (PDF) from the NICE Web site External Web Site Policy.
  • Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. Checklist for the diagnosis of stable angina. London (UK): National Institute for Health and Clinical Excellence; 2010. 6 p. (Clinical guideline; no. 95). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. Calcium scoring factsheet. London (UK): National Institute for Health and Clinical Excellence; 2010. 6 p. (Clinical guideline; no. 95). Electronic copies: Available Portable Document Format (PDF) from the NICE Web site External Web Site Policy.
  • Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. Patient questionnaire. London (UK): National Institute for Health and Clinical Excellence; 2010. 7 p. (Clinical guideline; no. 95). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. Baseline assessment spreadsheet. London (UK): National Institute for Health and Clinical Excellence; 2010. (Clinical guideline; no. 95). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • The guidelines manual 2007. London (UK): National Institute for Health and Clinical Excellence (NICE); 2007 April. Electronic copies: Available in Portable Document Format (PDF) from the NICE Web site External Web Site Policy.
Patient Resources

The following is available:

  • Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. Understanding NICE guidance - Information for people who use NHS services. London (UK): National Institute for Health and Clinical Excellence (NICE); 2010 Mar. (Clinical guideline; no. 95). Electronic copies: Available in English External Web Site Policy and Welsh External Web Site Policy from the NICE Web site.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on December 30, 2010. This summary was updated by ECRI Institute on December 16, 2013 following the U.S. Food and Drug Advisory (FDA) notice on Lexiscan (regadenoson) and Adenoscan (adenosine).

The National Institute for Health and Clinical Excellence (NICE) has granted the National Guideline Clearinghouse (NGC) permission to include summaries of their clinical guidelines with the intention of disseminating and facilitating the implementation of that guidance. NICE has not yet verified this content to confirm that it accurately reflects that original NICE guidance and therefore no guarantees are given by NICE in this regard. All NICE clinical guidelines are prepared in relation to the National Health Service in England and Wales. NICE has not been involved in the development or adaptation of NICE guidance for use in any other country. The full versions of all NICE guidance can be found at www.nice.org.uk External Web Site Policy.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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