National Institute for Health and Care Excellence updates the stable chest pain guideline with radical changes to the diagnostic paradigm

Abstract

In the 2016 update of the stable chest pain guideline, the National Institute for Health and Care Excellence (NICE) has made radical changes to the diagnostic paradigm that it—like other international guidelines—had previously placed at the centre of its recommendations. No longer are quantitative assessments of the disease probability considered necessary to determine the need for diagnostic testing and the choice of test. Instead, the recommendation is for no diagnostic testing if chest pain is judged to be ‘non-anginal’ and CT coronary angiography (CTCA) in patients with ‘typical’ or ‘atypical’ chest pain with additional perfusion imaging only if there is uncertainty about the functional significance of coronary lesions. The new emphasis on anatomical—as opposed to functional—testing is driven in large part by cost-effectiveness analysis and despite inevitable resource implications NICE calculates that annual savings for the population of England will be significant. In making CTCA the default diagnostic testing strategy in its updated chest pain guideline, NICE has responded emphatically to calls from trialists for CTCA to have a greater role in the diagnostic pathway of patients with suspected angina.

The National Institute for Health and Care Excellence update for stable chest pain: poorly reasoned and risky for patients

“…Yet, this problem warrants more careful history taking and the broader use of validated chest pain instruments, not more imaging. They also report that non-anginal chest pain accounts for one third of cardiac events during follow-up 1. This finding highlights the need for improved primary prevention, as very few of these patients were taking statins and antihypertensives.…”

“…With regard to diagnosis, the exercise ECG does not perform as well as imaging-based tests. However, in the meta-analysis discussed,1 variables that negatively impact test performance, such as upsloping ST depression, prior myocardial infarction, left bundle branch block, and pre-exercise hyperventilation, were included. Moreover, sensitivity of the exercise ECG for multivessel CAD does improve,6 though admittedly, the diagnostic performance is still inferior to imaging-based tests.…”

“…In their discussion of the lack of prognostic value of the exercise ECG,1 a minority of the patients actually had exercise data available, and the authors overemphasise the importance of the C statistic in risk prediction. For complex diseases, calibration is at least as important as the C statistic, and established cardiovascular risk factors may have little effect on the C statistic despite important effects on patient risk 7.…”

“…Unfortunately, in the latest iteration of the stable chest pain guidelines, NICE has veered dangerously off course by advocating that we abandon Bayesian analysis and simply order CT  coronary angiography (CTCA) in all patients with typical or atypical chest pain 1. The clinician should no longer consider a patient’s pretest probability, whether any imaging is necessary, and if so, which imaging test is best.…”

Anatomy and physiology in coronary artery disease imaging

“…This is a major step forward in accepting what has been discussed for more than a decade now. [10][11][12] This modification of the approach that has been anticipated by the implementation of CCT in the stratification of Chest Pain of recent onset in the context of ER (still from NICE in 2010) has the potential to radically change the way we make diagnosis, the way we treat our patients, and also the way we organize our services (Hospitals, Diagnostic Centers,…) in the clinical field.…”