Correspondence from the world of cardiology.
Do the NICE guidelines for chest pain add up?
The recent articles by Purvis and Hughes1 and Kelly et al.2 question the issued guidance from the National Institute of Health and Clinical Excellence (NICE) on the investigation of patients with recent onset chest pain.3 Purvis and Hughes focused on the investigation of patients in the low risk category for coronary artery disease (CAD), who under the NICE guidelines would be referred directly for computed tomography (CT) calcium scores (CTC) rather than exercise tolerance tests (ETTs), as is current practice in many hospitals. Their results were inconclusive, indicating that there may be a place for CTC above ETT. Kelly et al.2 applied the NICE guidelines to a patient cohort to investigate their implications upon service provision and cost for an NHS hospital. However, their study did not consider patient outcomes.
At our centre we performed a prospective three-month analysis of patients referred to secondary care for outpatient assessment of recent onset chest pain as part of our assessment of our chest pain service. These patients underwent clinical assessment and early ETT, as is the first line investigation within our hospital. The patients were followed up at one year, with data collected on further investigations performed, hospital admissions for chest pain, and adverse cardiac events (myocardial infarction and death). The NICE guidelines were then retrospectively applied to this patient cohort to categorise them into suggested risk categories and predict the initial diagnostic investigations advised.
80 patients were studied. Following exercise electrocardiogram (ECG), 19 patients were diagnosed with suspected CAD, and were either treated medically or underwent further investigation and/or intervention. A total of seven CTC scores +/- CT angiography was performed, and seven invasive angiographies. CAD was excluded in three patients, confirmed in nine, and one patient was still awaiting investigation at time of study. At one year there was only one hospital admission for cardiac chest pain in a patient already diagnosed with CAD following exercise tolerance testing. There were no adverse cardiac outcomes, against a predicted 3.6 adverse events for this patient cohort.4
Had the NICE guidelines been applied to this group one year previously, 80 fewer exercise ECGs would have been performed, but an additional 10 CTC scores, 21 non-invasive functional imaging tests, and 12 coronary angiograms would have been performed as first-line investigation. Applying these guidelines would not have improved patient outcomes at one year. Taking the cost of the investigation itself as well as travel expenses, applying the NICE guidelines to this three-month patient cohort would have cost an additional £15,399 (as per Jersey costs) or £16,759 (as per costs assumed by NICE). It is likely that actual cost would be even greater after subsequent investigations had also been performed.
Jersey General Hospital is an isolated district general hospital in the British Isles and local cardiac services are limited to ETTs, CTC and CT angiography. The NICE guidelines assume easy access to a wide range of cardiac services, and whilst these guidelines may be more easily applied in large tertiary centres, the same may not apply in isolated district general hospitals. Our study suggests that applying the NICE guidelines would be at increased cost, without clear patient benefit (at one year) and would expose patients to the risks and hazards of more complex investigation. We therefore agree with the concerns put forward in the article by Purvis and Hughes.1 As well as this we add a further dimension to the research of Kelly et al.2 through the consideration of patient outcomes.
Rebecca Cooper, FY2
Royal Bournemouth Hospital, Castle Lane East, Bournemouth, Dorset BH7 7DW
Emma Eade, FY2
Chelsea and Westminster Hospital, 369 Fulham Road London SW10 9NH
Andrew RJ Mitchell
The Jersey Heart and Lung Unit, General Hospital, St Helier, Jersey, JE1 3QS
1. Purvis JA, Hughes SM. Could coronary artery calcium scores replace exercise stress testing? A DGH analysis. Br J Cardiol 2011;18:120–3.
2. Kelly D et al. Implementation of the new NICE guidelines for stable chest pain: likely impact on chest pain services in the UK. Br J Cardiol 2011;18:184–8.
3. National Institute for Health and Clinical Excellence. Chest pain of recent onset. Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. London: NICE, 2010. Available from: http://www.nice.org.uk/guidance/CG95
4. Kones R. Recent advances in the management of chronic stable angina I: Approach to the patient, diagnosis, pathophysiology, risk stratification, and gender disparities. Vasc Health Risk Manag. 2010;6:635–56. http://dx.doi.org/10.2147/VHRM.S7564 PMid:20730020 PMCid:2922325