New NICE guidance on chest pain of recent onset

Br J Cardiol 2010;17:109-10 Leave a comment
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It is hoped that a new National Institute for Health and Clinical Excellence (NICE) guideline on recent onset chest pain will lead to a reduction in cardiovascular deaths.

The guideline, jointly developed with the National Clinical Guidelines Centre for Acute and Chronic Conditions, represents a significant change in practice in some key areas of diagnosing acute coronary sydromes (ACS) and angina.

The focus of the new guideline is on the diagnosis of chest pain which is suspected to be of cardiac origin, so that appropriate treatment can be provided.

It notes that chest pain is experienced by some 20–40% of the general population at some time during their lives, and accounts for up to 1% of visits to GPs, approximately 700,000 visits (5%) to emergency departments and up to 25% of emergency admissions to hospital.

The guideline has two separate diagnostic pathways. The first is for patients with acute chest pain who may have an ACS and the second is for those with intermittent stable chest pain of suspected cardiac origin who may have stable angina.

Recommendations in the guideline for people with suspected ACS include:

  • 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.
  • Do not exclude 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, to guide the use of supplemental oxygen.
  • Do not assess symptoms of an ACS differently in different ethnic groups.

Recommendations for people with intermittent stable chest pain who may have stable angina include:

  • Diagnose stable angina based on either clinical assessment alone or where there is uncertainty, clinical assessment plus diagnostic testing.
  • If people have features of typical angina based on clinical assessment and their estimated likelihood of coronary artery disease (CAD) is greater than 90%, further diagnostic investigation is unnecessary and should be managed 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 and first consider causes of pain other than angina (such as gastrointestinal or musculoskeletal pain).
  • In people without confirmed CAD, in whom a diagnosis of stable angina cannot be made or excluded based on clinical assessment alone, estimate the likelihood of CAD, taking into account the clinical assessment and the resting 12-lead ECG. Arrange further diagnostic testing according to the estimated likelihood of CAD.
  • Do not use exercise ECG to diagnose or exclude stable angina for people without known CAD.

For full guidance, visit This clinical guideline partially updates NICE technology appraisal guidance 73.