NICE guidelines for the management of patients with acute chest pain

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Sara Zand, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3]; Priyamvada Singh, M.B.B.S. [4]

Overview[edit | edit source]

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 Acute Chest Pain [1][edit | edit source]

  • If the patient is currently pain-free, but had chest pain in the last 12 hours, and resting 12-lead ECG is abnormal or not available or develops further chest pain after recent (confirmed or suspected) ACS, evaluation about ACS is warranted.
  • Management of ACS:
  • Assessment of patients with suspected ACS in the hospital:

· Repeated resting 12-lead ECGs · Checking pain relief

  • Use of high-sensitivity troponin tests is not recommended, if ACS is not suspected
  • For patients at high or moderate risk of MI (as indicated by a validated tool), performing high sensitivity troponin tests is reasonable.
  • For patients at low risk of MI :
  • Performing a second high-sensitivity troponin test
  • Considering a single high-sensitivity troponin test only at presentation to rule out NSTEMI , if the first troponin test is below the lower limit of detection (negative).
  • A detectable troponin on the first high-sensitivity test does not necessary for patients with confirmed MI.
  • For diagnose of ACS use of biochemical markers such as natriuretic peptides and high-sensitivity C-reactive protein are not recommended.

.

  • Factors should be considered for interpreting high-sensitivity troponin:
  • the clinical presentation
  • The time from onset of symptoms
  • The resting 12-lead ECG findings
  • The pre-test probability of NSTEMI
  • The length of time since the suspected ACS
  • The probability of chronically elevated troponin levels in some patients
  • That 99th percentile threshold for troponin I and T may differ between sexes.

References[edit | edit source]

  1. Carrabba N, Migliorini A, Pradella S, Acquafresca M, Guglielmo M, Baggiano A, Moscogiuri G, Valenti R (2018). "Old and New NICE Guidelines for the Evaluation of New Onset Stable Chest Pain: A Real World Perspective". Biomed Res Int. 2018: 3762305. doi:10.1155/2018/3762305. PMC 6250018. PMID 30533431.


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