View source for NICE guidelines for the management of patients with stable chest pain

{{Chest pain}}
{{CMG}}; '''Associate Editor(s)-In-Chief:'''{{Sara.Zand}} {{CZ}}; [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com]

==Overview==
In the 2016 update of the stable [[chest pain]] guideline, [[National Institute for Health and Clinical Excellence]] ([[NICE]]) has dramatically changed its approach to new-onset stable [[chest pain]] aiming to find a more cost-effective strategy including NO use of pretest probability risk scores or NO use of functional tests, such as [[stress echocardiography]], as a first-line investigation. The suggestion is to use CT coronary angiography in [[patients] with typical or atypical [[chest pain]]. In addition, there is no recommendation for any diagnostic testing if [[chest pain]] is non-anginal. Also, [[perfusion imaging]] is offered in the setting of uncertainty about the functional significance of [[coronary]] lesions. However, the recommendation of the [[European Society of Cardiology]] ([[ESC]]—2013) is functional tests as the initial investigation.

==NICE Guidelines for the Management of Patients with Stable Chest Pain<ref name="pmid30533431">{{cite journal |vauthors=Carrabba N, Migliorini A, Pradella S, Acquafresca M, Guglielmo M, Baggiano A, Moscogiuri G, Valenti R |title=Old and New NICE Guidelines for the Evaluation of New Onset Stable Chest Pain: A Real World Perspective |journal=Biomed Res Int |volume=2018 |issue= |pages=3762305 |date=2018 |pmid=30533431 |pmc=6250018 |doi=10.1155/2018/3762305 |url=}}</ref>==


Clinical assessment 
*Taking a detailed clinical [[history]] about:
*  [[age]] and [[sex]] 
* Characteristics of the pain, including location, radiation, severity, duration, frequency, 
* Provoking and relieving factors
*  Associated symptoms, such as [[breathlessness]] 
*History of [[angina]], [[MI]], [[coronary revascularization]], or other [[cardiovascular disease]] 
* [[Cardiovascular]] risk factors
*:: [[Physical examination]] to
*identifying risk factors for [[cardiovascular disease]]
* identifying signs of another [[cardiovascular disease]]
* identifying non-coronary causes of [[angina]] ( severe [[aortic stenosis]], [[cardiomyopathy]]) 
* excluding other causes of [[chest pain]]

* Assessment of  the typicality of chest pain as follows:
* Presence of three of the features below is defined as typical [[angina]].
· Presence of two of the three features below is defined as atypical [[angina]].
· Presence of one or none of the features below is defined as non-anginal [[chest pain]].
Anginal pain is:
* Constricting discomfort in the front of the [[chest]], or in the [[neck]], [[shoulders]], [[jaw]], or [[arms]]
* Precipitated by [[physical exertion]] 
* relieved by [[rest]] or [[TNG]] within about 5 minutes
* Typical and atypical features of anginal [[chest pain]] and non-anginal [[chest pain]] are not defined 
differently in [[men]] and [[women]] in [[ethnic]] groups. 
*: Stable [[angina]] is  more likely based on characteristics of: 
* [[Age]]
* [[Male ]] [[sex]]
* [[Cardiovascular]] risk factors including:
*[[Smoking]]
* [[Diabetes]]
* [[Hypertension]]
* [[Dyslipidemia]] 
*[[Family history]] of premature [[CAD]]
* other [[cardiovascular]] disease
* History of established [[CAD]], for example previous [[MI]], [[coronary revascularization]]

*Features that make a diagnosis of [[stable angina]] unlikely are when the [[chest pain]] is:
* Continuous or very prolonged
*Unrelated to activity 
* Increased by [[inspiration]]
* Associated with [[symptoms]] such as [[dizziness]], [[palpitations]], [[tingling ]] or difficulty [[swallowing]]
*Considering causes of [[chest pain]] other than angina (such as [[gastrointestinal]] or [[musculoskeletal pain]])
* Investigating other causes of [[angina]], such as [[hypertrophic cardiomyopathy]], in [[patients]] with typical angina-like [[chest pain]] and a low likelihood of [[CAD]] is considered.
* Factors that exacerbate [[angina]], such as [[anemia]], for all [[patients]] with [[stable angina]] should be considered.
*Only consider [[chest X-ray]] if other diagnoses, such as a [[lung tumor]], are suspected.
* If a diagnosis of [[stable angina]] has been excluded, but the [[patient]]s have risk factors for [[cardiovascular disease]], follow the appropriate guidance, for example, the NICE  guideline on [[hypertension]].
* For [[suspected]] stable angina on the basis of the clinical assessment alone, taking a resting 12-lead [[ECG]] as soon as possible after the presentation is recommended.
* The diagnosis of [[stable angina ]] is not ruled out on the basis of a normal resting 12-lead [[ECG]].
* For [[patients]] with non-anginal [[chest pain]] on clinical assessment, [[diagnostic testing]] is not recommended, unless there are resting ECG ST-T changes or Q waves.
* Resting 12-lead [[ECG]] changes consistent with [[CAD ]] are: 
*[[Ischaemia]] or previous [[infarction]]
* Pathological Q waves
* [[LBBB]] 
* [[ST-segment ]] and [[T wave abnormalities]] ( flattening or inversion). 
*: Any resting 12-lead [[ECG ]] changes together with people’s clinical history and risk factors should be considered.


*:  Consider [[aspirin]] only if the  [[chest pain]] is likely to be stable angina until a diagnosis is made.
*If the [[patient]] is already taking [[aspirin]] or is allergic to it, do not offer additional [[aspirin]]. 

*The Guideline Development Group emphasized that the recommendations in this guideline are to make a diagnosis of chest pain, not to screen for [[CAD]].
* Most people diagnosed with non-anginal [[chest pain]] after [[clinical]] assessment need no further diagnostic testing. However in a very small number of 
people, there are remaining concerns that the pain could be [[ischaemic]].
*:: 64-slice (or above) CT coronary angiography is recommended in the presence of:
* Recent-onset [[chest pain]] of suspected [[cardiac]] origin
* Clinical assessment indicating typical or [[atypical angina]]
* Clinical assessment indicating non-anginal [[chest pain]] but ST-T changes or Q waves in resting [[ECG]]
*: For [[patients]] with confirmed [[CAD]] ( previous [[MI]], [[revascularization]], previous [[angiography]]), non-invasive functional testing  is recommended when there is uncertainty about whether [[chest pain]] is caused by [[myocardial ischaemia]]. 
* An [[exercise ECG]] may be used instead of functional imaging.
* Non-invasive functional imaging for [[myocardial ischemia]] is recommended if 64-slice (or above) CT coronary angiography has shown [[ CAD ]] of uncertain functional significance or is nondiagnostic.
* [[Invasive coronary angiography]]  is offered as a third-line investigation when the results of non-invasive functional imaging are inconclusive.
*: Use of non-invasive functional testing for [[myocardial ischemia]]
* [[Myocardial perfusion scintigraphy]] with [[single-photon emission] computed tomography [[(MPS]] with [[SPECT]]) or
* [[Stress echocardiography]] 
* First-pass contrast-enhanced [[magnetic resonance]] (MR) perfusion 
*[[ MR imaging]] for stress-induced [[wall motion abnormalitie]]s 
*:: Consider locally available technology and expertise, the person and their preferences, and any 
contraindications (for example, [[disabilities]], [[frailty]], limited ability to [[exercise]]) when deciding on the 
imaging method.

* Use [[adenosine]], [[dipyridamole]], or [[dobutamine]] as stress agents for [[MPS]] with [[SPECT]] and 
[[adenosine]] or [[dipyridamole]] for first-pass contrast-enhanced [[MR perfusion]].
* Use [[exercise]] or [[dobutamine]] for [[stress echocardiography]] or MR imaging for stress-induced 
[[wall motion abnormalities]].
* Use of MR [[coronary angiography]] for diagnosing [[stable angina]] is not recommended.
* Use  of [[exercise ECG]] to diagnose or exclude [[stable angina]] for [[patients]] without known [[CAD]] is not recommended.
*::Definition of [[CAD]]:
*Significant [[coronary artery disease]] ([[CAD]]) in CT coronary angiography  ≥ 70% 
*Diameter stenosis of at least one major [[epicardial artery]] segment or ≥ 50% diameter stenosis in the [[left main coronary artery]]
*::  Investigation about other causes of angina, such as [[hypertrophic cardiomyopathy]] or [[syndrome X]] is recommended in [[patients]] with typical angina-like [[chest pain]] if investigation excludes flow-limiting 
disease in the [[epicardial coronary arteries]].

==References==
{{reflist|2}}

[[Category:Cardiology]]
[[Category:Pulmonology]]
[[Category:Emergency medicine]]
[[Category:Gastroenterology]]
[[Category:Mature chapter]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date cardiology]]

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