Guidance update: latest NICE guidelines on chest pain

Dr Ivan Benett and Dr Toni Hazell offer a free module on how to implement NICE guidance on chest pain of recent origin.

1. Introduction
2. What is the latest evidence?
3. What’s new in the latest guidance?
4. What to do differently in your practice?
5. Any areas of uncertainty/controversy?
6. New and upcoming treatments
7. Multimorbidity
8. Case study
9. Quality improvement activities
10. Key points
11. Useful resources
12. References


1. Introduction

Chest pain is a common presentation, accounting for 1-2% of all adult consultations in primary care, 5% of visits to emergency departments and 40% of emergency hospital admissions.1


2. What is the latest evidence?

The NICE guidance on chest pain of recent onset that was published in 2010 was updated in November 2016.2


3. What’s new in the latest guidance?

The main change that is relevant to GPs is the section on assessing a patient with stable chest pain and deciding who should be referred. This section assumes that the person does not have current pain and that the pain has not occurred in the last 72 hours – patients who have had pain in this time frame should be referred more urgently. This is discussed in more detail later in this module.

Unchanged from 2010 (and from what we all learnt in medical school) is the advice that we should take a history and examine, with a view both to diagnosing angina and assessing for other causes. New in the 2016 guidance is that we should assess the pain according to how typical it is for angina. Anginal pain can have three characteristics (Box 1).

Box 1. Characteristics of anginal pain
  • Constricting discomfort in the front of the chest or in the neck, shoulders, jaw or arms
  • Precipitated by physical exertion
  • Relieved by rest or glyceryl trinitrate (GTN) within about five minutes

If the patient’s pain has all three of these characteristics then it is classed as typical angina, whereas two of these characteristics is atypical angina and one or none is non-anginal chest pain. An assessment of the typicality of chest pain should be included in any referral to secondary care. Those with non-anginal chest pain should not be offered diagnostic investigations for chest pain unless a resting ECG shows ST changes or Q waves – left bundle branch block is also highlighted as an abnormality that may indicate ischaemia or previous infarction.

Any patient in whom angina cannot be excluded should have a resting ECG taken as soon as possible and we should also consider the possibility of other diagnoses such as hypertrophic cardiomyopathy in patients with anginal pain who have a low likelihood of coronary artery disease. A chest X-ray should only be requested if an alternative diagnosis such as lung cancer is being considered.

This assessment should be the same for both men and women and for patients from different ethnic groups. Other features that make anginal pain unlikely are if the pain is continuous or very prolonged, unrelated to activity, brought on by breathing in or associated with dizziness, palpitations, tingling or difficulty swallowing. An alternative diagnosis should be sought in patients with chest pain that is not felt to be of cardiac origin.

This guidance formalises the assessment of stable chest pain that we were probably all making anyway and so is unlikely to change what an experienced GP will be doing now, though it may be useful for teaching purposes. It could be useful for medico-legal purposes because it backs up a decision not to refer a patient whose symptoms do not suggest angina.

Important! An assessment of the typicality of chest pain should be included in any referral to secondary care.


4. What to do differently in your practice?

There is also a section in the guidance on acute chest pain, which hasn’t been updated since 2010 but is worth highlighting. Anyone who has had chest pain in the last 12 hours should be treated the same as those who have chest pain at the time of assessment and referred to hospital, if a resting ECG is abnormal or not available. Of course, a normal resting ECG does not rule out acute coronary syndrome (something that isn’t made clear in the guidance) and clinical judgment may well still support an emergency referral even in the presence of a normal ECG. Those who have had pain in the last 72 hours but are now pain-free with a normal resting ECG should be referred for ‘urgent same-day assessment… if there are no reasons for emergency referral’ – in most areas emergency referral and same-day assessment are essentially the same thing, so we should maybe consider referring all patients who have had pain in the last 72 hours.


Any patient in whom angina cannot be excluded should have a resting ECG taken as soon as possible

Other reasons to refer would include a suspicion of a complication such as pulmonary oedema after chest pain has settled, or further chest pain after a recent episode of acute coronary syndrome, which may be caused by further coronary disease, pericarditis and Dressler’s syndrome, or pulmonary embolus.


5. Any areas of uncertainty/controversy?

The guidance is slightly contradictory when it comes to the investigation of patients who have no features or only one feature of anginal pain. It initially says that these patients have ‘non-anginal chest pain’, which would suggest that the clinical assessment has ruled out angina and no further tests are needed. However, it then says that we should assess the likelihood of coronary artery disease (using the usual risk factors such as age, diabetes, lipids, hypertension, family history, etc) and that those with non-anginal chest pain should only be referred if there are ECG changes – but if the guidance is followed to the letter, and patients with no features or only one feature of anginal pain are considered not to have angina, then it doesn’t obviously follow that a resting ECG would have been requested. In the presence of this slight confusion, and in these litigious times, it would seem sensible to have a low threshold for requesting a resting ECG in patients who have any anginal features or risk factors in whom you are not considering a referral to secondary care.


6. New and upcoming treatments

NICE now advises that any patient who has a clinical assessment suggesting typical or atypical angina should have a CT coronary angiography which takes 64 slices or more as their initial test. This should also be the case for those whose history does not suggest angina but who have ST changes or Q waves on a resting ECG. If the CT is not diagnostic then non-invasive functional imaging should be offered eg stress echo, exercise ECG, perfusion scintigraphy or MRI, with invasive angiography being reserved as third-line.

Clearly, these decisions won’t be made in primary care but this information may be useful for those GPs who are involved in commissioning secondary care services, or those who need to make a decision about which of several local hospitals to use for chest pain referrals.

Important! Any patient who has a clinical assessment suggesting typical or atypical angina should have a CT coronary angiography which takes 64 slices or more as their initial test.


7. Multimorbidity

There are no specific multimorbidity issues in this guidance, except that those patients with multiple risk factors for cardiovascular disease may be more likely to have angina as a cause for their chest pain than those without.


8. Case study

Maria is a 65-year-old woman who comes to see you complaining of chest pain, on and off for the last month or so. She last had it one week ago. The pain is mainly there when she climbs stairs or if she runs for a bus but she is vague about how quickly it goes when she stops exerting herself. It is a tight squeezing type pain. She has well-controlled hypertension but is otherwise healthy. You explain to her that the pain sounds like angina, though the uncertainty about how quickly it goes away on rest would put it in the category of atypical angina. You arrange for a resting ECG and refer her to your local rapid access chest pain clinic.

Two weeks later you get a letter from the chest pain clinic saying that she has had a CT angiography that shows coronary artery disease and she is on the waiting list for an angioplasty. This is subsequently carried out and a stent is inserted.

You see Maria three months later for a review of her blood pressure and she is delighted to tell you that she has no chest pain now and thanks you for your prompt action.


9. Quality improvement activities

  • Review the last five referrals to your local rapid access chest pain clinic. Had a clear assessment been made of the typicality of the pain and was this communicated in the referral letter?
  • Consider having a standard letter with space to add information on typicality of chest pain as a reminder to anyone who is referring
  • Audit and review your arrangements for checking resting ECGs that are brought into your practice. Do they go to the duty doctor or the doctor who had requested the ECG? What happens if the requesting doctor is away? Do you need a more cast-iron system to ensure that they are all reviewed on the same day and any relevant action taken?

10. Key points

  • Anyone who has current chest pain or has had chest pain in the last 12 hours should be referred to hospital as an emergency, and those who have had chest pain in the last 72 hours should be referred on the same day
  • Assess the typicality of stable chest pain and use this assessment to guide your decisions on investigation and referral
  • If coronary disease cannot be excluded then the best next test is to use CT angiography to make the diagnosis. If there is remaining doubt after a CT angiogram, then use functional imaging to rule out false positive results
  • If no significant coronary artery disease is found, consider and investigate for other causes of the symptoms. These may be cardiac, such as valve disease, or non-cardiac, such as musculoskeletal pain or gastro-oesophageal reflux

11. Useful resources

MIMS. Anti-anginal preparations, summary by pharmacological class. Details of available formulations of anti-anginal drugs listed by pharmacological class.

MIMS. Cardiology clinic. Latest news and quick-reference resources to support primary care prescribing for cardiovascular conditions, including angina, heart failure and hypertension.

Patient.info. Chest pain. April 2016


12. References

  1. NICE. Clinical knowledge summary: Chest pain: prevalence. January 2017.
  2. NICE. Chest pain of recent onset: assessment and diagnosis. CG95. Updated November 2016.
  • Dr Ivan Benett is a GPSI cardiology in Manchester
  • Dr Toni Hazell is a GP in London

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