Transcript Chest pain algorithm

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Implementing NICE Guidance
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Chest pain algorithm
Incorporating the treatment and management
algorithms from the NICE guidelines on chest pain
of recent onset, unstable angina and NSTEMI,
and stable angina
Implementing NICE guidance
NICE clinical guidelines 94, 95 and 126
3rd Edition – March 2014
Contents slide
Recent acute chest pain
algorithm
(including diagnosis of acute chest pain and
management of unstable angina and
A
NSTEMI)
Stable chest pain algorithm
(including diagnosis of stable chest pain and
management of stable angina)
B
Algorithm close: find out more and tell us what you think
C
Shortcut to diagnosis of acute chest pain
Shortcut to management of unstable angina and NSTEMI
Shortcut to management of stable angina
Shortcut to diagnosis of stable chest pain
Implementing NICE Guidance
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3
People presenting with acute chest pain
Yes
Acute coronary syndrome (ACS)
suspected? (checking for
suspected ACS)
• Start management immediately
(box 1)
• Do not delay transfer to hospital
• Current chest pain or
• Recent ACS and further chest pain
develops
No
Consider other causes of chest
pain, including potentially lifethreatening ones
No current chest pain
Refer to hospital for assessment as an emergency
Shortcut to Initial assessment
Implementing NICE Guidance
< slide 3 Contents
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4
Acute chest pain – referral to hospital
No current chest pain
• Chest pain more than 72 hours ago
• No complications
Chest pain in the last 12 hours
or
or
Signs of complications e.g. pulmonary
oedema
A
Chest pain 12–72 hours ago
Both boxes recommend an initial assessment
Click here to move to initial assessment
C
Implementing NICE Guidance
B
< slide 4 ACS suspected?
www.nice.org.uk
5
Acute chest pain – referral to hospital
• Chest pain more than 72 hours
ago
• No complications
Carry out an assessment. Decide if
referral is:
• necessary
• urgent
Signs of complications e.g.
pulmonary oedema
Decide if referral should be:
• as an emergency
or
• for urgent same-day assessment
Return to slide 5 No current chest pain
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6
Acute chest pain – Referral to hospital
Chest pain in the last 12 hours
Resting 12-lead ECG
abnormal or unavailable
Refer to hospital for
assessment as an
emergency
Chest pain 12–72 hours ago
• Resting 12-lead ECG
normal
• No reasons for emergency
Refer to hospital for urgent same-day
assessment
Return to slide 5 No current chest pain
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7
Acute chest pain – in hospital
Initial assessment
(see box 3)
ECG findings
• Regional ST-segment
elevation or
• Presumed new left bundle
branch block (LBBB)?
Yes / No
Troponin levels
If initial troponin is raised:
• consider other causes e.g. myocarditis, aortic
dissection or pulmonary embolism
• follow local protocols for STEMI or NICE
clinical guideline on unstable angina and
NSTEMI
• continue monitoring (box 2)
Repeat troponin 10–12 hours after onset of
symptoms
Shortcut to management of unstable angina and NSTEMI
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8
Acute chest pain – in hospital
• Regional ST-segment elevation or
• Presumed LBBB?
Yes
No
Follow local protocols for ST-segmentelevation myocardial infarction (STEMI)
until firm diagnosis made
Continue monitoring (box 2)
Regional ST-segment depression or deep
T wave inversion suggestive of NSTEMI
or unstable angina?
A
Yes
Move to Diagnosis
D
Implementing NICE Guidance
B
No
C
< slide 8 Initial assessment
www.nice.org.uk
9
Acute chest pain – in hospital
The person has regional ST-segment
depression or deep T wave inversion
suggestive of NSTEMI or unstable angina
• Follow NICE clinical guideline on unstable angina and
NSTEMI until firm diagnosis made
• Continue monitoring (box 2)
Return to slide 9 Regional ST-segment
elevation or presumed LBBB
Implementing NICE Guidance
Shortcut to management of unstable
angina and NSTEMI
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10
Acute chest pain – in hospital
The person does not have regional ST-segment depression or deep T wave
inversion suggestive of NSTEMI or unstable angina
• Increase suspicion of an ACS if there are Q waves and T wave changes, even
without ST-segment changes. Consider following NICE clinical guideline on
unstable angina and NSTEMI if unstable angina or NSTEMI is likely
• Consider taking serial ECGs, reviewing previous ECGs and recording additional
leads
• Consider other life-threatening conditions (e.g. pulmonary embolism, aortic
dissection or pneumonia)
• Continue monitoring (box 2)
Return to slide 9 Regional ST-segment
elevation or presumed LBBB
Implementing NICE Guidance
Shortcut to management of unstable
angina and NSTEMI
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11
Acute chest pain – diagnosis
Diagnostic criteria met? (box 4)
No
Yes
Treat according to
local protocols for
STEMI or NICE
management of
unstable angina /
NSTEMI
C
Uncertain
• Reassess
• If myocardial ischaemia suspected,
see diagnosis of stable chest pain
• Use clinical judgement to decide on
timing of further investigations
Continue
monitoring
(box 2)
A
B
End of acute chest pain diagnosis algorithm.
Shortcut to contents page
< slide 9 Regional ST-segment
elevation or presumed LBBB?
Shortcut to algorithm close: Find out more
and tell us what you think
Shortcut to diagnosis of stable
chest pain
Implementing NICE Guidance
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12
The early management of unstable angina and NSTEMI
• Offer a single loading dose of 300 mg aspirin and continue aspirin indefinitely
• Offer fondaparinux to patients without a high bleeding risk unless angiography is
planned within 24 hours
• Offer unfractionated heparin if angiography is likely within 24 hours
• Carefully consider choice and dose of antithrombin for patients with a high bleeding
risk (see box 11)
–
Consider unfractionated heparin, with dose adjusted to clotting function, if
creatinine > 265 micromoles per litre
Continue
Implementing NICE Guidance
< slide 12 the end of the acute chest
pain diagnosis algorithm
www.nice.org.uk
13
Unstable angina/NSTEMI
Use established scoring system such as GRACE (see box 10) to predict 6-month mortality
and assess risk of future adverse cardiovascular events1. Assess bleeding risk (see box 11)
and pertinent comorbidity before considering treatments and at each stage of
management
• Lowest risk (≤ 1.5%)2
• Low risk (> 1.5–3.0%)2
A
• Intermediate risk (> 3.0–6.0%)2
• High risk (> 6.0–9.0%)2
• Highest risk (> 9.0%)2
B
Hyperlink to online GRACE calculator
(not endorsed by NICE)
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14
Unstable angina/NSTEMI
Low risk
(> 1.5–3.0%)1
Lowest risk (≤ 1.5%)1
Offer clopidogrel as a treatment option for up to
12 months to people who have had an NSTEMI,
regardless of treatment
Initial conservative management
Recurrent spontaneous
ischaemia?
Yes
No
Consider ischaemia testing
Ischaemia demonstrated?
Implementing NICE Guidance
Yes
No
Coronary
angiography
Discuss
management
with
interventional
cardiologist and
cardiac surgeon
Conservative
management
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15
Unstable angina/NSTEMI
Discuss management with cardiologist and cardiac surgeons. Consider
angiographic findings, comorbidities and risks and benefits when discussing
the choice of revascularisation strategy with the patient
Conservative
management
Percutaneous coronary
intervention (PCI)
A
< slide 15 Low and lowest risk
Implementing NICE Guidance
Coronary artery bypass
grafting (CABG)
B
C
Return to slide 14 containing risk
classifications
D
www.nice.org.uk
16
Unstable angina/NSTEMI
Percutaneous coronary intervention (PCI)
• Consider abciximab for patients not on a glycoprotein IIb/IIIa inhibitor (GPI)
(eptifibatide, tirofiban)
• Offer systemic unfractionated heparin (50–100 units/kg) to patients on
• fondaparinux
• Consider bivalirudin as an alternative to the combination of a heparin plus a
GPI for patients not on a GPI or fondaparinux
Return to slide 16 Discuss management
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17
Unstable angina/NSTEMI
Coronary artery bypass grafting (CABG)
• Consider stopping clopidogrel 5 days before CABG in patients with low risk of
adverse cardiovascular events
• Discuss with surgeon whether to continue clopidogrel before CABG in patients
with intermediate or higher risk of adverse cardiovascular events
Return to slide 16 Discuss management
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18
Unstable angina/NSTEMI
Intermediate risk
(> 3.0–6.0%)1
High risk
(> 6.0–9.0%)1
Highest risk
(> 9.0%)1
• Offer clopidogrel as a treatment option for up to 12 months to people who have had an
NSTEMI, regardless of treatment.
• Balance potential reduction in ischaemic risk with risk of bleeding and consider:
– adding a GPI (eptifibatide or tirofiban), or
– bivalirudin as an alternative to the combination of a heparin plus a GPI if the patient
is not on fondaparinux or a GPI and angiography is scheduled within 24 hours of
admission
Continue
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19
Unstable angina/NSTEMI
Management of intermediate risk, high risk
and highest risk continued
Offer coronary angiography (with follow-on PCI if indicated) within 96 hours of first
admission unless contraindicated. Perform as soon as possible if patient is clinically
unstable or at high ischaemic risk
Discuss management strategy with interventional cardiologist and cardiac surgeon.
< slide 19 intermediate, high and highest risk
Implementing NICE Guidance
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20
Unstable angina/NSTEMI
Discuss management with cardiologist and cardiac surgeon. Consider
angiographic findings, comorbidities and risks and benefits when discussing
the choice of revascularisation strategy with the patient
Conservative
management
Percutaneous coronary
intervention (PCI)
A
Coronary artery bypass
grafting (CABG)
B
C
End of unstable angina/NSTEMI algorithm return
to the contents slide
D
Shortcut to algorithm close: Find out more and tell
us what you think
Implementing NICE Guidance
< slide 19 Intermediate,
high and highest risk
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21
Unstable angina/NSTEMI
Percutaneous coronary intervention (PCI)
• Consider abciximab for patients not on a GPI (eptifibatide, tirofiban)
• Offer systemic unfractionated heparin (50–100 units/kg) to patients on
fondaparinux
• Consider bivalirudin as an alternative to the combination of a heparin plus a
GPI for patients not on a GPI or fondaparinux
Return to slide 21 Discuss management
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22
Unstable angina/NSTEMI
Coronary artery bypass grafting (CABG)
• Consider stopping clopidogrel 5 days before CABG in patients with low risk of
adverse cardiovascular events
• Discuss with surgeon whether to continue clopidogrel before CABG in
patients with intermediate or higher risk of adverse cardiovascular events
Return to slide 21 Discuss management
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23
People presenting with stable chest pain
Carry out a clinical assessment (box 5)
Does the person
have confirmed
coronary artery
disease (CAD)1?
A
• Does the person have
features of typical or
atypical angina and
• Is stable angina suspected
based on history and risk
factors? (box 6)
• Does the person have
non-anginal chest pain
and
• Stable angina is not
suspected based on
history and risk factors?
(box 6)
E
C
Yes
B
Yes
D
Yes
F
< slide 3 contents
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24
Stable chest pain
• Yes the person has non-anginal chest pain
and
• Stable angina is not suspected based on history and risk factors?
(box 6)
• Consider other causes of chest pain such as gastrointestinal or
musculoskeletal pain
• Only consider chest X-ray if other diagnoses (e.g. lung tumour)
are suspected
Return to slide 24 Cinical assessment
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25
Stable chest pain
Yes the person has confirmed
CAD1?
• Treat as stable angina if symptoms are typical of stable angina
• If uncertain that chest pain is caused by myocardial ischaemia offer:
– non-invasive functional imaging (follow 30–60% pathway and box 8)
or
– exercise ECG testing.
Shortcut to 30-60% diagnostic pathway
Shortcut to management of stable angina
Implementing NICE Guidance
Return to slide 24 Clinical assessment
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26
Stable chest pain
• Yes, the person has features of typical or atypical angina and
• stable angina is suspected based on history and risk factors (box 6)
• Take a resting 12-lead ECG as soon as possible (box 7)
• Use clinical assessment, ECG results and typicality of anginal pain features to estimate
the likelihood of CAD (box 6 and table 1)
Estimated likelihood
of CAD is less than
10%
A
• Estimated likelihood of CAD is
more than 90% and
• Person has features of typical
angina
B
Estimated
likelihood of CAD
is 10–90%
C
< slide 24 Clinical assessment
Implementing NICE Guidance
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27
Stable chest pain
• Estimated likelihood of CAD is more than
90% and
• Person has features of typical angina
• Arrange blood tests for conditions which
exacerbate angina
• Treat as stable angina with no further
diagnostic tests
Shortcut to management
of stable angina
Implementing NICE Guidance
Return to slide 27 Stable angina is suspected
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28
Stable chest pain
Estimated likelihood of
CAD is less than 10%
• First consider other causes of chest pain such as gastrointestinal or
musculoskeletal pain
• Only consider chest X-ray if other diagnoses (e.g. lung tumour) are
suspected
• Consider investigating other causes of angina (e.g. hypertrophic
cardiomyopathy) if there is typical angina-like chest pain
Return to slide 27 Stable angina suspected
Implementing NICE Guidance
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29
Stable chest pain
Estimated likelihood of CAD is 10–90%
• Arrange blood tests for conditions which exacerbate angina
• Consider aspirin only if chest pain is likely to be stable angina. Do not offer if being
taken regularly or the person is allergic
• Treat as stable angina while waiting for the results if symptoms are typical of stable
angina
Offer diagnostic testing (see boxes below) if stable angina cannot be confirmed or
excluded
Diagnostic testing when
estimated likelihood of
CAD is 10–29%
A
Diagnostic testing when
estimated likelihood of
CAD is 30–60% B
Move to management of stable angina
Implementing NICE Guidance
D
Diagnostic testing when
estimated likelihood of
CAD is 61-90% C
< slide 27 Stable angina suspected
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30
Stable chest pain – diagnostic testing
Estimated likelihood of CAD is 10–29%
Offer CT calcium scoring
If score is 0: investigate
other causes of chest
pain1
If score is 1–400:
offer 64-slice (or above) CT
coronary angiography
If score is > 400: follow
pathway for
61–90% CAD
Significant CAD? (box 9)
Yes / No / Uncertain
Shortcut to 61-90% likelihood of CAD
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31
Stable chest pain – diagnostic testing
Significant CAD? (box 9)
Yes
Uncertain
Offer non-invasive functional imaging
(box 8)
Treat as stable
angina
No
Investigate other
causes of chest
pain1
Reversible myocardial ischaemia?
Yes
Treat as stable
angina
No
Investigate other causes
of chest pain1
Return to slide 30 containing all risk classifications
Shortcut to management of stable angina
Implementing NICE Guidance
< slide 28 Likelihood
of CAD 10–29%
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32
Stable chest pain –
diagnostic testing
Estimated likelihood of CAD is 30–60%
Offer non-invasive functional imaging (box 8)
Uncertain
Offer invasive coronary
angiography
Reversible myocardial ischaemia?
Yes
Treat as stable angina
No
Investigate other causes
of chest pain1
Significant CAD? (box 9)
Yes
Treat as stable angina
No
Investigate other causes
of chest pain1
Return to slide 30 containing all risk classifications
Implementing NICE Guidance
Shortcut to management
of stable angina
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33
Stable chest pain – diagnostic testing
Estimated likelihood of CAD is 61–90%
Is invasive coronary angiography appropriate and
acceptable and is coronary revascularisation
being considered?
No
A
Yes
B
< slide 30 Estimated likelihood of CAD 10–90%
Implementing NICE Guidance
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34
Stable chest pain – diagnostic testing
Likelihood of CAD is 61–90% and invasive coronary
angiography is not appropriate or acceptable and coronary
revascularisation is not being considered
Offer non-invasive functional imaging (box 8)
Reversible myocardial ischaemia?
No
Investigate other causes of chest pain1
Return to slide 34 Estimated
likelihood of CAD 61–90%
Implementing NICE Guidance
Yes
Treat as stable angina
Shortcut to management of stable angina
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35
Stable chest
pain –
diagnostic
testing
Likelihood of CAD is 61–90% and invasive coronary
angiography is appropriate and acceptable and coronary
revascularisation is being considered
Offer invasive coronary angiography
Significant CAD? (box 9)
Yes
Treat as stable
angina
Yes
Uncertain
Offer non-invasive
functional imaging (box 8)
Reversible myocardial ischaemia?
No
Investigate other
causes of chest pain1
No
Return to slide 30 Estimated likelihood 10-90%
End of stable chest pain diagnosis algorithm.
Shortcut to return to contents page
Implementing NICE Guidance
Shortcut to management
of stable angina
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36
Stable angina
Management of stable angina
Stable angina diagnosed in line with ‘chest pain of recent onset’
• Offer advice, information and support (see box 12)
• Take into account general principles for treating stable angina see box 13
• Offer a short-acting nitrate (see box 14).
• Offer optimal drug treatment (one or two anti-anginal drugs as necessary plus
drugs for secondary prevention of cardiovascular disease; see box 15).
• Offer either a beta blocker or calcium channel blocker as first-line treatment, based
on contraindications, comorbidities and the person’s preference.
• Do not routinely offer other anti-anginal drugs as first-line treatment.
Are symptoms satisfactorily controlled and medication tolerated?
Yes
Shortcut to diagnosis of stable chest pain
Implementing NICE Guidance
No
< slide 30 estimated likelihood of CAD 10−90%
www.nice.org.uk
37
Stable angina
Symptoms satisfactorily controlled with optimal drug treatment
• Discuss:
– the prognosis without further investigation
– the likelihood of having left main stem or proximal three-vessel disease
– CABG surgery to improve the prognosis in left main stem or proximal three-vessel
disease
– the process and risks of investigation
– the benefits and risks of CABG, including potential survival gain.
• After discussion consider:
– a functional or non-invasive anatomical test to identify people who might benefit
from surgery1. Results may be available from diagnostic assessment
– coronary angiography if the test shows extensive ischaemia or likely left main stem
or proximal three-vessel disease, and revascularisation is acceptable and
appropriate
– CABG if coronary angiography shows left main stem or proximal three-vessel
disease and the coronary anatomy is suitable.
Return to slide 37 ‘Are symptoms satisfactorily controlled and medication tolerated?’
Implementing NICE Guidance
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38
Stable angina
Symptoms are not satisfactorily controlled or medication
is not tolerated?
BB or CCB tolerated but
symptoms not
controlled
A
Both BB and CCB are
contraindicated or not
tolerated
B
CCB or BB is
contraindicated or
not tolerated
C
If stable angina does not respond to drug treatment and/or revascularisation
Implementing NICE Guidance
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D
39
Stable angina
If a calcium channel blocker is
contraindicated or not tolerated, consider
a beta blocker C
If a beta blocker is contraindicated or
not tolerated, consider a calcium
channel blocker C
• If symptoms are not satisfactorily controlled, consider adding:
– a long-acting nitrate or ivabradine1 or nicorandil2 or ranolazine.
• Decide which drug based on comorbidities, contraindications, person’s preference and
drug costs.
• Do not offer a third anti-anginal drug if stable angina is controlled with two antianginal drugs.
• Consider adding a third anti-anginal drug only when:
– two anti-anginal drugs do not satisfactorily control symptoms and
– the person is waiting for revascularisation or revascularisation is not considered
appropriate or acceptable.
• Decide which drug based on comorbidities, contraindications, the person’s preference
and drug costs.
Are symptoms satisfactory controlled?
Implementing NICE Guidance
< slide 37 stable angina diagnosed
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40
Stable angina
Medical management of stable
angina. Are symptoms
satisfactorily controlled?
Yes
A
No
B
Return to slide 39 Combinations of drug treatments
Implementing NICE Guidance
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41
Stable angina
Symptoms satisfactorily controlled with optimal drug treatment
• Discuss:
– the prognosis without further investigation
– the likelihood of having left main stem or proximal three-vessel disease
– CABG surgery to improve the prognosis in left main stem or proximal threevessel disease
– the process and risks of investigation
– the benefits and risks of CABG, including potential survival gain.
• After discussion consider:
– a functional or non-invasive anatomical test to identify people who might
benefit from surgery1. Results may be available from diagnostic assessment
– coronary angiography if the test shows extensive ischaemia or likely left main
stem or proximal three-vessel disease, and revascularisation is acceptable and
appropriate
– CABG if coronary angiography shows left main stem or proximal three-vessel
disease and the coronary anatomy is suitable.
Return to slide 41 – Are symptoms satisfactorily controlled?
Implementing NICE Guidance
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42
Stable angina
•
•
•
•
•
•
Symptoms not satisfactorily controlled with optimal drug treatment
Consider revascularisation (coronary artery bypass graft [CABG] or percutaneous
coronary intervention [PCI]).
Offer coronary angiography to guide treatment strategy.
Additional non-invasive or invasive functional testing may be needed1.
Consider the risks and benefits of continuing drug treatment or performing
revascularisation and provide information (see boxes 16 and 17 ).
If the coronary anatomy is suitable and revascularisation is appropriate:
– offer CABG if PCI is not appropriate
– offer PCI if CABG is not appropriate.
If either CABG or PCI is appropriate take into account:
– that for people with anatomically less complex disease who do not have a
preference for one procedure PCI may be more cost effective
– the potential survival advantage of CABG for people with multivessel disease
who:
o have diabetes or are over 65 or have anatomically complex three-vessel
disease, with or without involvement of the left main stem.
Return to slide 41 – Are symptoms satisfactorily controlled?
Implementing NICE Guidance
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43
Stable angina
If either a beta blocker or calcium channel blocker does not satisfactorily control
symptoms, consider the other option (that is, calcium channel blocker or beta
blocker) or consider both drugs together1
A
• Do not offer a third anti-anginal drug if stable angina is controlled with two antianginal drugs.
• Consider adding a third anti-anginal drug only when:
– two anti-anginal drugs do not satisfactorily control symptoms and
– the person is waiting for revascularisation or revascularisation is not considered
appropriate or acceptable.
• Decide which drug based on comorbidities, contraindications, the person’s
preference and drug costs.
Are symptoms satisfactorily controlled?
< slide 37 stable angina diagnosed
Implementing NICE Guidance
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44
Stable angina
Medical management of stable
angina. Are symptoms
satisfactorily controlled?
Yes
A
No
B
Return to slide 39- Combinations of drug treatments
Implementing NICE Guidance
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45
Stable angina
Symptoms satisfactorily controlled with optimal drug treatment
• Discuss:
– the prognosis without further investigation
– the likelihood of having left main stem or proximal three-vessel disease
– CABG surgery to improve the prognosis in left main stem or proximal threevessel disease
– the process and risks of investigation
– the benefits and risks of CABG, including potential survival gain.
• After discussion consider:
– a functional or non-invasive anatomical test to identify people who might
benefit from surgery1. Results may be available from diagnostic assessment
– coronary angiography if the test shows extensive ischaemia or likely left main
stem or proximal three-vessel disease, and revascularisation is acceptable and
appropriate
– CABG if coronary angiography shows left main stem or proximal three-vessel
disease and the coronary anatomy is suitable.
Return to slide 45 – Are symptoms satisfactorily controlled?
Implementing NICE Guidance
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46
Stable angina
•
•
•
•
•
•
Symptoms not satisfactorily controlled with optimal drug treatment
Consider revascularisation (coronary artery bypass graft [CABG] or percutaneous
coronary intervention [PCI]).
Offer coronary angiography to guide treatment strategy.
Additional non-invasive or invasive functional testing may be needed1.
Consider the risks and benefits of continuing drug treatment or performing
revascularisation and provide information (see boxes 16 and 17 ).
If the coronary anatomy is suitable and revascularisation is appropriate:
– offer CABG if PCI is not appropriate
– offer PCI if CABG is not appropriate.
If either CABG or PCI is appropriate take into account:
– that for people with anatomically less complex disease who do not have a
preference for one procedure PCI may be more cost effective
– the potential survival advantage of CABG for people with multivessel disease
who:
o have diabetes or are over 65 or have anatomically complex three-vessel
disease, with or without involvement of the left main stem.
Return to slide 45 – Are symptoms satisfactorily controlled?
Implementing NICE Guidance
www.nice.org.uk
47
Stable angina
 If both beta blockers and calcium channel blockers are
contraindicated or not tolerated, consider monotherapy with:
– a long-acting nitrate or
– ivabradine or
– nicorandil or
– ranolazine.
 Decide which drug based on comorbidities, contraindications,
person’s preference and drug costs.
B
Are symptoms satisfactorily controlled?
< slide 37 stable angina diagnosed
Implementing NICE Guidance
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48
Stable angina
Medical management of stable
angina. Are symptoms
satisfactorily controlled?
Yes
A
No
B
Return to slide 39 combinations of drug treatments
Implementing NICE Guidance
www.nice.org.uk
49
Stable angina
Symptoms satisfactorily controlled with optimal drug treatment
• Discuss:
– the prognosis without further investigation
– the likelihood of having left main stem or proximal three-vessel disease
– CABG surgery to improve the prognosis in left main stem or proximal three-vessel
disease
– the process and risks of investigation
– the benefits and risks of CABG, including potential survival gain.
• After discussion consider:
– a functional or non-invasive anatomical test to identify people who might benefit
from surgery1. Results may be available from diagnostic assessment
– coronary angiography if the test shows extensive ischaemia or likely left main stem
or proximal three-vessel disease, and revascularisation is acceptable and
appropriate
– CABG if coronary angiography shows left main stem or proximal three-vessel
disease and the coronary anatomy is suitable.
Return to slide 49 – are symptoms satisfactorily controlled
Implementing NICE Guidance
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50
Stable angina
•
•
•
•
•
•
Symptoms not satisfactorily controlled with optimal drug treatment
Consider revascularisation (coronary artery bypass graft [CABG] or percutaneous
coronary intervention [PCI]).
Offer coronary angiography to guide treatment strategy.
Additional non-invasive or invasive functional testing may be needed1.
Consider the risks and benefits of continuing drug treatment or performing
revascularisation and provide information (see boxes 16 and 17 ).
If the coronary anatomy is suitable and revascularisation is appropriate:
– offer CABG if PCI is not appropriate
– offer PCI if CABG is not appropriate.
If either CABG or PCI is appropriate take into account:
– that for people with anatomically less complex disease who do not have a
preference for one procedure PCI may be more cost effective
– the potential survival advantage of CABG for people with multivessel disease
who:
o have diabetes or are over 65 or have anatomically complex three-vessel
disease, with or without involvement of the left main stem.
Return to slide 49 – Are symptoms satisfactorily controlled?
Implementing NICE Guidance
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51
Stable angina
• If stable angina does not respond to drug treatment and/or revascularisation, reevaluate. This may include:
– exploring the person’s understanding of their condition and the impact of
symptoms on quality of life
– reviewing the diagnosis and considering non-ischaemic causes of pain
– reviewing drug treatment and considering future drug treatment and
revascularisation options
– acknowledging the limitations of further treatment
– explaining how the person can manage their pain themselves
– specific attention to the role of psychological factors in pain
– developing skills to modify cognitions and behaviours associated with pain.
• Consider cardiac syndrome X in people with angiographically normal coronary
arteries and continuing anginal symptoms:
– continue drug treatment for stable angina if symptoms improve
– do not routinely offer drugs for secondary prevention of cardiovascular
disease.
Return to the contents page
Implementing NICE Guidance
< slide 37 management of stable angina
www.nice.org.uk
52
Box 1 Immediate management of a suspected ACS
In the order appropriate to the circumstances, offer:
• pain relief (GTN and/or an intravenous opioid)
• a single loading dose of 300 mg aspirin unless the person is allergic. Send a
written record with the person if given before arriving at hospital. Only offer
other antiplatelet agents1 in hospital
• a resting 12-lead ECG. Send to the hospital before the person arrives if possible
• other therapeutic interventions1 as necessary
• pulse oximetry, ideally before hospital admission. Offer oxygen:
– if oxygen saturation (SpO2) is less than 94% with no risk of hypercapnic
respiratory failure. Aim for SpO2 of 94–98%
– to people with chronic obstructive pulmonary disease who are at risk of
hypercapnic respiratory failure. Aim for SpO2 of 88–92% until blood gas analysis
is available
• monitoring (box 2).
< slide 4 ACS suspected
Implementing NICE Guidance
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Box 2 Monitor until diagnosis
• Include:
– exacerbations of pain and/or other symptoms
– pulse and blood pressure
– heart rhythm
– oxygen saturation by pulse oximetry
– repeated resting 12-lead ECGs
– checking pain relief is effective.
• Decide how often this should be done.
< box 1 Immediate management
Implementing NICE Guidance
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Box 2 Monitor until diagnosis
• Include:
– exacerbations of pain and/or other symptoms
– pulse and blood pressure
– heart rhythm
– oxygen saturation by pulse oximetry
– repeated resting 12-lead ECGs
– checking pain relief is effective.
• Decide how often this should be done.
< slide 8 Initial assessment
Implementing NICE Guidance
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Box 2 Monitor until diagnosis
• Include:
– exacerbations of pain and/or other symptoms
– pulse and blood pressure
– heart rhythm
– oxygen saturation by pulse oximetry
– repeated resting 12-lead ECGs
– checking pain relief is effective.
• Decide how often this should be done.
< slide 9 ST-segment elevation and new LBBB
Implementing NICE Guidance
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Box 2 Monitor until diagnosis
• Include:
– exacerbations of pain and/or other symptoms
– pulse and blood pressure
– heart rhythm
– oxygen saturation by pulse oximetry
– repeated resting 12-lead ECGs
– checking pain relief is effective.
• Decide how often this should be done.
< slide 10 yes ST-segment depression or T wave inversion
Implementing NICE Guidance
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Box 2 Monitor until diagnosis
• Include:
– exacerbations of pain and/or other symptoms
– pulse and blood pressure
– heart rhythm
– oxygen saturation by pulse oximetry
– repeated resting 12-lead ECGs
– checking pain relief is effective.
• Decide how often this should be done.
< slide 11 no ST-segment depression or T wave inversion
Implementing NICE Guidance
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Box 2 Monitor until diagnosis
• Include:
– exacerbations of pain and/or other symptoms
– pulse and blood pressure
– heart rhythm
– oxygen saturation by pulse oximetry
– repeated resting 12-lead ECGs
– checking pain relief is effective.
• Decide how often this should be done.
< slide 12 diagnostic criteria
Implementing NICE Guidance
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Box 3 Initial assessment
Clinical history (unless STEMI is confirmed from the resting 12-lead ECG)
• Record:
– the characteristics of the pain
– associated symptoms
– history of cardiovascular disease
– any cardiovascular risk factors
– details of investigations or treatments for similar symptoms of chest pain.
Physical examination
• Check:
– haemodynamic status
– for signs of complications (e.g. pulmonary oedema, cardiogenic shock)
– for signs of non-coronary causes of acute chest pain (e.g. aortic dissection).
ECG
• Take a resting 12-lead ECG.
• Do not exclude an ACS if the resting 12-lead ECG is normal.
• Obtain a review of ECGs by a healthcare professional qualified to interpret them as well as any
automated interpretation.
Biochemical markers
• Take blood for troponin I or T.
• When interpreting troponin, take into account the clinical presentation, time from onset of
symptoms and the resting 12-lead ECG findings.
• Do not use:
– natriuretic peptides or high sensitivity C-reactive protein to diagnose an ACS
– biochemical markers of myocardial ischaemia (such as ischaemia-modified albumin).
Implementing NICE Guidance
< slide 8 initial assessment
www.nice.org.uk
Box 4 Diagnostic criteria for myocardial infarction1
Detection of rise and/or fall of cardiac biomarkers (preferably troponin) with at least
one value above the 99th percentile of the upper reference limit, together with
evidence of myocardial ischaemia with at least one of the following:
• symptoms of ischaemia
• ECG changes indicative of new ischaemia (new ST-T changes or new LBBB)
• development of pathological Q wave changes in the ECG
• imaging evidence of new loss of viable myocardium or new regional wall motion
abnormality2
< slide 12 diagnostic criteria
Implementing NICE Guidance
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Box 5 Clinical assessment
Clinical history
• Record:
– age and sex
– pain characteristics, factors provoking and relieving the pain
– associated symptoms
– history of cardiovascular disease
– cardiovascular risk factors.
Physical examination
• Identify cardiovascular risk factors.
• Look for signs of other cardiovascular disease.
• Exclude:
– non-coronary causes of angina (e.g. severe aortic stenosis, cardiomyopathy)
– other causes of chest pain.
< slide 24 stable chest pain clinical assessment
Implementing NICE Guidance
www.nice.org.uk
Box 6 Features of stable angina
• Anginal pain is:
– constricting discomfort in the front of the chest, neck, shoulders, jaw or arms
– precipitated by physical exertion
– relieved by rest or GTN in about 5 minutes.
• People with typical angina have all the above anginal pain features, people with atypical
angina have two of the features and people with non-anginal chest pain have one or
none of the features.
• Do not define typical and atypical features of anginal and non-anginal chest pain
differently in men and women or among ethnic groups.
• Factors making stable angina more likely:
– increasing age
– whether the person is male
– cardiovascular risk factors
– a history of established CAD (e.g. previous MI, coronary revascularisation).
• Stable angina is unlikely if the pain is:
– continuous or very prolonged and/or
– unrelated to activity and/or
– brought on by breathing in and/or
– associated with dizziness, palpitations, tingling or difficulty swallowing.
< slide 24 stable chest pain clinical assessment
Implementing NICE Guidance
www.nice.org.uk
Box 6 Features of stable angina
• Anginal pain is:
– constricting discomfort in the front of the chest, neck, shoulders, jaw or arms
– precipitated by physical exertion
– relieved by rest or GTN in about 5 minutes.
• People with typical angina have all the above anginal pain features, people with
atypical angina have two of the features and people with non-anginal chest pain
have one or none of the features.
• Do not define typical and atypical features of anginal and non-anginal chest pain
differently in men and women or among ethnic groups.
• Factors making stable angina more likely:
– increasing age
– whether the person is male
– cardiovascular risk factors
– a history of established CAD (e.g. previous MI, coronary revascularisation).
• Stable angina is unlikely if the pain is:
– continuous or very prolonged and/or
– unrelated to activity and/or
– brought on by breathing in and/or
– associated with dizziness, palpitations, tingling or difficulty swallowing.
< slide 25 non-anginal chest pain
Implementing NICE Guidance
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Box 6 Features of stable angina
• Anginal pain is:
– constricting discomfort in the front of the chest, neck, shoulders, jaw or arms
– precipitated by physical exertion
– relieved by rest or GTN in about 5 minutes.
• People with typical angina have all the above anginal pain features, people with atypical
angina have two of the features and people with non-anginal chest pain have one or
none of the features.
• Do not define typical and atypical features of anginal and non-anginal chest pain
differently in men and women or among ethnic groups.
• Factors making stable angina more likely:
– increasing age
– whether the person is male
– cardiovascular risk factors
– a history of established CAD (e.g. previous MI, coronary revascularisation).
• Stable angina is unlikely if the pain is:
– continuous or very prolonged and/or
– unrelated to activity and/or
– brought on by breathing in and/or
– associated with dizziness, palpitations, tingling or difficulty swallowing.
< slide 27 stable angina suspected
Implementing NICE Guidance
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Box 7 Resting 12-lead ECG testing
• Do not rule out stable angina based on a normal ECG.
• Consider ECG changes with people’s clinical history and risk factors. Changes
consistent with CAD which may indicate ischaemia or previous infarction
include:
– pathological Q waves in particular
– LBBB
– ST-segment and T wave abnormalities (e.g. flattening or inversion).
Results may not be conclusive.
< slide 27 stable angina suspected
Implementing NICE Guidance
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Box 8 Non-invasive functional testing
• Offer1:
– MPS with SPECT2 or
– stress echocardiography or
– first-pass contrast-enhanced magnetic resonance (MR) perfusion or
– MR imaging for stress-induced wall motion abnormalities.
• Take account of local availability and expertise and the person’s
contraindications and preferences.
• Use adenosine, dipyridamole or dobutamine as stress agents for MPS with
SPECT.
• Use adenosine or dipyridamole for first-pass contrast-enhanced MR perfusion.
• Use exercise or dobutamine for stress echocardiography or MR imaging for
stress-induced wall motion abnormalities.
• Do not use:
– MR coronary angiography for diagnosing stable angina
– exercise ECG to diagnose or exclude stable angina in people without known
CAD.
< slide 26 confirmed CAD
Implementing NICE Guidance
www.nice.org.uk
Box 8 Non-invasive functional testing
• Offer1:
– MPS with SPECT2 or
– stress echocardiography or
– first-pass contrast-enhanced magnetic resonance (MR) perfusion or
– MR imaging for stress-induced wall motion abnormalities.
• Take account of local availability and expertise and the person’s
contraindications and preferences.
• Use adenosine, dipyridamole or dobutamine as stress agents for MPS with
SPECT.
• Use adenosine or dipyridamole for first-pass contrast-enhanced MR perfusion.
• Use exercise or dobutamine for stress echocardiography or MR imaging for
stress-induced wall motion abnormalities.
• Do not use:
– MR coronary angiography for diagnosing stable angina
– exercise ECG to diagnose or exclude stable angina in people without known
CAD.
< slide 32 significant CAD
Implementing NICE Guidance
www.nice.org.uk
Box 8 Non-invasive functional testing
• Offer1:
– MPS with SPECT2 or
– stress echocardiography or
– first-pass contrast-enhanced magnetic resonance (MR) perfusion or
– MR imaging for stress-induced wall motion abnormalities.
• Take account of local availability and expertise and the person’s
contraindications and preferences.
• Use adenosine, dipyridamole or dobutamine as stress agents for MPS with
SPECT.
• Use adenosine or dipyridamole for first-pass contrast-enhanced MR perfusion.
• Use exercise or dobutamine for stress echocardiography or MR imaging for
stress-induced wall motion abnormalities.
• Do not use:
– MR coronary angiography for diagnosing stable angina
– exercise ECG to diagnose or exclude stable angina in people without known
CAD.
< slide 33 likelihood of CAD 30−60%
Implementing NICE Guidance
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Box 8 Non-invasive functional testing
• Offer1:
– MPS with SPECT2 or
– stress echocardiography or
– first-pass contrast-enhanced magnetic resonance (MR) perfusion or
– MR imaging for stress-induced wall motion abnormalities.
• Take account of local availability and expertise and the person’s contraindications
and preferences.
• Use adenosine, dipyridamole or dobutamine as stress agents for MPS with SPECT.
• Use adenosine or dipyridamole for first-pass contrast-enhanced MR perfusion.
• Use exercise or dobutamine for stress echocardiography or MR imaging for stressinduced wall motion abnormalities.
• Do not use:
– MR coronary angiography for diagnosing stable angina
– exercise ECG to diagnose or exclude stable angina in people without known
CAD.
< slide 35 invasive coronary angiography not appropriate
Implementing NICE Guidance
www.nice.org.uk
Box 8 Non-invasive functional testing
• Offer1:
– MPS with SPECT2 or
– stress echocardiography or
– first-pass contrast-enhanced magnetic resonance (MR) perfusion or
– MR imaging for stress-induced wall motion abnormalities.
• Take account of local availability and expertise and the person’s contraindications
and preferences.
• Use adenosine, dipyridamole or dobutamine as stress agents for MPS with SPECT.
• Use adenosine or dipyridamole for first-pass contrast-enhanced MR perfusion.
• Use exercise or dobutamine for stress echocardiography or MR imaging for stressinduced wall motion abnormalities.
• Do not use:
– MR coronary angiography for diagnosing stable angina
– exercise ECG to diagnose or exclude stable angina in people without known
CAD.
< slide 36 invasive coronary angiography is appropriate
Implementing NICE Guidance
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Box 9 Coronary artery disease
Significant CAD on invasive coronary angiography is ≥ 70% diameter stenosis of at
least one major epicardial artery segment or ≥ 50% diameter stenosis in the left
main coronary artery.
Factors intensifying ischaemia
• Such factors allow less severe lesions (e.g. ≥ 50%) to produce angina:
• reduced oxygen delivery: anaemia, coronary spasm
• increased oxygen demand: tachycardia, left ventricular hypertrophy
• large mass of ischaemic myocardium: proximally located lesions
• longer lesion length.
Factors reducing ischaemia
Such factors may make severe lesions (≥ 70%) asymptomatic:
• well-developed collateral supply
• small mass of ischaemic myocardium: distally located lesions, old infarction in the
territory of coronary supply.
< slide 31 likelihood of CAD 10−29%
Implementing NICE Guidance
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Box 9 Coronary artery disease
Significant CAD on invasive coronary angiography is ≥ 70% diameter stenosis of at
least one major epicardial artery segment or ≥ 50% diameter stenosis in the left
main coronary artery.
Factors intensifying ischaemia
• Such factors allow less severe lesions (e.g. ≥ 50%) to produce angina:
• reduced oxygen delivery: anaemia, coronary spasm
• increased oxygen demand: tachycardia, left ventricular hypertrophy
• large mass of ischaemic myocardium: proximally located lesions
• longer lesion length.
Factors reducing ischaemia
Such factors may make severe lesions (≥ 70%) asymptomatic:
• well-developed collateral supply
• small mass of ischaemic myocardium: distally located lesions, old infarction in
the territory of coronary supply.
< slide 32 significant CAD
Implementing NICE Guidance
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Box 9 Coronary artery disease
Significant CAD on invasive coronary angiography is ≥ 70% diameter stenosis of at
least one major epicardial artery segment or ≥ 50% diameter stenosis in the left
main coronary artery.
Factors intensifying ischaemia
• Such factors allow less severe lesions (e.g. ≥ 50%) to produce angina:
• reduced oxygen delivery: anaemia, coronary spasm
• increased oxygen demand: tachycardia, left ventricular hypertrophy
• large mass of ischaemic myocardium: proximally located lesions
• longer lesion length.
Factors reducing ischaemia
Such factors may make severe lesions (≥ 70%) asymptomatic:
• well-developed collateral supply
• small mass of ischaemic myocardium: distally located lesions, old infarction in
the territory of coronary supply.
< slide 33 likelihood of CAD 30−60%
Implementing NICE Guidance
www.nice.org.uk
Box 9 Coronary artery disease
Significant CAD on invasive coronary angiography is ≥ 70% diameter stenosis of at
least one major epicardial artery segment or ≥ 50% diameter stenosis in the left
main coronary artery.
Factors intensifying ischaemia
• Such factors allow less severe lesions (e.g. ≥ 50%) to produce angina:
• reduced oxygen delivery: anaemia, coronary spasm
• increased oxygen demand: tachycardia, left ventricular hypertrophy
• large mass of ischaemic myocardium: proximally located lesions
• longer lesion length.
Factors reducing ischaemia
Such factors may make severe lesions (≥ 70%) asymptomatic:
• well-developed collateral supply
• small mass of ischaemic myocardium: distally located lesions, old infarction in
the territory of coronary supply.
< slide 36 likelihood of CAD 61−90%
Implementing NICE Guidance
www.nice.org.uk
Box 10 – Factors to include when assessing risk with an established scoring
system
•
•
•
•
Full clinical history (including age, previous MI, previous PCI or CABG)
Physical examination (including blood pressure and heart rate)
Twelve-lead resting ECG
Blood tests (such as troponin I or T, creatinine, glucose and haemoglobin)
< slide 14 unstable angina/NSTEMI low risk to high risk
Implementing NICE Guidance
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Box 11 – Factors associated with high bleeding risk
•
•
•
•
Advancing age
Known bleeding complications
Renal impairment
Low body weight
< slide 13 unstable angina/NSTEMI
Implementing NICE Guidance
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Box 11 – Factors associated with high bleeding risk
•
•
•
•
Advancing age
Known bleeding complications
Renal impairment
Low body weight
< slide 14 unstable angina/NSTEMI low risk to high risk
Implementing NICE Guidance
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Box 12 Offering advice, information and support
• Include the person’s family or carers in discussions when appropriate.
• Explain stable angina, factors provoking it and its long-term course and
management.
• Encourage questions and provide opportunities for the person to discuss
concerns, ideas and expectations about their condition, prognosis and
treatment.
• Explore and address any misconceptions about stable angina and its
implications for daily activities, heart attack risk and life expectancy.
• Discuss the purpose, risks and benefits of treatment.
• Assess the need for lifestyle advice and psychological support. Offer
interventions as necessary.
• Explore and address issues such as self-management skills, concerns about the
impact of stress, anxiety or depression on angina and physical exertion including
sex.
• Advise the person to seek professional help if their angina suddenly worsens.
< slide 37 stable angina diagnosed
Implementing NICE Guidance
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Box 13 General principles for treating stable angina
Do not:
• exclude people from treatment based on their age alone
• investigate or treat symptoms differently based on gender or ethnic
group
• offer vitamins or fish oil. Inform people there is no evidence that they
help stable angina.
• offer transcutaneous electrical nerve stimulation (TENS), enhanced
external counterpulsation (EECP) or acupuncture to manage stable
angina.
< slide 37 stable angina diagnosed
Implementing NICE Guidance
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Box 14 Short-acting nitrates for preventing and treating angina
• Advise people:
– how to administer short-acting nitrates
– to use immediately before planned exercise or exertion
– side-effects such as flushing, headache and light-headedness may
occur
– to sit down or hold on to something if feeling light-headed.
• When used to treat episodes of angina advise people:
– to repeat the dose after 5 minutes if the pain has not gone
– to call an emergency ambulance if the pain has not gone 5 minutes
after the second dose.
< slide 37 stable angina diagnosed
Implementing NICE Guidance
www.nice.org.uk
Box 15 Optimal drug treatment
• Optimal drug treatment is one or two anti-anginal drugs as necessary plus drugs
for secondary prevention of cardiovascular disease.
• Provide information about drugs in line with ‘Medicines adherence’ (NICE clinical
guideline 76).
Anti-anginal drug treatment
• Advise people that anti-anginal drug treatment aims to prevent episodes of angina
and secondary prevention aims to prevent cardiovascular events such as heart
attack and stroke.
• Discuss how side effects of drug treatment might affect daily activities, and the
importance of taking drug treatment regularly.
• Review response to treatment, including any side effects, 2–4 weeks after starting
or changing drug treatment.
• Titrate dosage against symptoms up to the maximum tolerable dosage.
Secondary prevention
• Consider aspirin 75 mg daily. Take into account risk of bleeding and comorbidities.
• Consider angiotensin-converting enzyme (ACE) inhibitors for people with stable
angina and diabetes. Offer or continue ACE inhibitors for other conditions, in line
with the relevant NICE guidance.
• Offer statins in line with ‘Lipid modification’ (NICE clinical guideline 67).
• Offer treatment for high blood pressure in line with ‘Hypertension’ (NICE clinical
guideline 127).
Implementing NICE Guidance
< slide 37 stable angina diagnosed
www.nice.org.uk
Box 16 Risk and benefits
• Consider the relative risks and benefits of CABG and PCI using a systematic
approach to assess severity and complexity of coronary disease and other
relevant clinical factors and comorbidities.
• Ensure regular multidisciplinary team discussion about treatment strategy for
people, including but not limited to:
– people with left main stem or anatomically complex three-vessel disease or
– when there is doubt about the best method of revascularisation because of
coronary anatomy, extent of stenting required or other relevant clinical
factors or comorbidities.
• The multidisciplinary team should include interventional cardiologists and
cardiac surgeons.
< slide 43 did not respond to treatment
Implementing NICE Guidance
www.nice.org.uk
Box 16 Risk and benefits
• Consider the relative risks and benefits of CABG and PCI using a systematic
approach to assess severity and complexity of coronary disease and other
relevant clinical factors and comorbidities.
• Ensure regular multidisciplinary team discussion about treatment strategy for
people, including but not limited to:
– people with left main stem or anatomically complex three-vessel disease or
– when there is doubt about the best method of revascularisation because of
coronary anatomy, extent of stenting required or other relevant clinical
factors or comorbidities.
• The multidisciplinary team should include interventional cardiologists and
cardiac surgeons.
< slide 47 did not respond to treatment
Implementing NICE Guidance
www.nice.org.uk
Box 16 Risk and benefits
• Consider the relative risks and benefits of CABG and PCI using a systematic
approach to assess severity and complexity of coronary disease and other
relevant clinical factors and comorbidities.
• Ensure regular multidisciplinary team discussion about treatment strategy for
people, including but not limited to:
– people with left main stem or anatomically complex three-vessel disease or
– when there is doubt about the best method of revascularisation because of
coronary anatomy, extent of stenting required or other relevant clinical
factors or comorbidities.
• The multidisciplinary team should include interventional cardiologists and
cardiac surgeons.
< slide 51 did not respond to treatment
Implementing NICE Guidance
www.nice.org.uk
Box 17 Information about PCI and CABG
• Ensure people receive balanced information and have the opportunity to
discuss the benefits, limitations and risks of continuing drug treatment, CABG
and PCI to help them make an informed decision.
• If either CABG or PCI is appropriate, explain:
– the main purpose of revascularisation is to improve symptoms
– CABG and PCI are effective in relieving symptoms
– repeat revascularisation may be needed and the rate is lower after CABG
– stroke is uncommon and the incidence is similar with CABG and PCI
– the potential survival advantage with CABG for some people with
multivessel disease.
• Discuss the practical aspects including vein and/or artery harvesting, likely
length of hospital stay, recovery time and drug treatment after the procedure.
< slide 43 did not respond to treatment
Implementing NICE Guidance
www.nice.org.uk
Box 17 Information about PCI and CABG
• Ensure people receive balanced information and have the opportunity to
discuss the benefits, limitations and risks of continuing drug treatment, CABG
and PCI to help them make an informed decision.
• If either CABG or PCI is appropriate, explain:
– the main purpose of revascularisation is to improve symptoms
– CABG and PCI are effective in relieving symptoms
– repeat revascularisation may be needed and the rate is lower after CABG
– stroke is uncommon and the incidence is similar with CABG and PCI
– the potential survival advantage with CABG for some people with
multivessel disease.
• Discuss the practical aspects including vein and/or artery harvesting, likely
length of hospital stay, recovery time and drug treatment after the procedure.
< slide 47 did not respond to treatment
Implementing NICE Guidance
www.nice.org.uk
Box 17 Information about PCI and CABG
• Ensure people receive balanced information and have the opportunity to
discuss the benefits, limitations and risks of continuing drug treatment, CABG
and PCI to help them make an informed decision.
• If either CABG or PCI is appropriate, explain:
– the main purpose of revascularisation is to improve symptoms
– CABG and PCI are effective in relieving symptoms
– repeat revascularisation may be needed and the rate is lower after CABG
– stroke is uncommon and the incidence is similar with CABG and PCI
– the potential survival advantage with CABG for some people with
multivessel disease.
• Discuss the practical aspects including vein and/or artery harvesting, likely
length of hospital stay, recovery time and drug treatment after the procedure.
< slide 51 did not respond to treatment
Implementing NICE Guidance
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< slide 27 stable angina is suspected
Implementing NICE Guidance
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Find out more and tell us what you
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Find out more – Unstable angina and
NSTEMI guideline
Visit www.nice.org.uk/guidance/CG94 for:
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the guideline
the quick reference guide
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slide set
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Find out more – Chest pain of recent
onset guideline
Visit www.nice.org.uk/guidance/CG95 for:
• the guideline
• the quick reference guide
• ‘Understanding NICE guidance’
• slide set
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• audit support
• implementation advice
• online educational tool
• referral checklist
• calcium scoring factsheet
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Find out more – Stable angina
guideline
Visit www.nice.org.uk/guidance/CG126 for:
• the guideline
• the quick reference guide
• ‘Understanding NICE guidance’
• slide set
• costing statement
• audit support
• baseline assessment tool
• factsheet on revascularisation for stable angina
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Find out more – related guidance
Visit www.nice.org.uk for guidance on:
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•
•
•
•
•
•
•
•
Stable angina quality standard
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Hypertension
Management of hyperglycaemia in patients with ACS
Chronic heart failure
Ticagrelor
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MI: secondary prevention
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Recent acute chest pain diagnosis
Acute coronary syndrome
suspected – management
and referral
Contents slide
No current chest pain
– management and
referral
Clinical assessment:
• Confirmed CAD
• Non-anginal chest pain – stable angina not suspected
• Stable angina suspected
Diagnosis of stable angina in people with suspected stable angina
when estimated likelihood of coronary artery disease:
- is more than 90%
- is less than 10%
- is 10−90%
Acute chest pain assessment:
• ECG findings
• Tropinin results
Further diagnostic testing of people with suspected stable
angina and estimated likelihood of CAD of:
- 10–29%
- 30–60%
- 61–90%
Diagnosis in people with acute chest pain
Diagnosis of unstable angina or NSTEMI confirmed (option at
this point to escape algorithm)
Management of unstable angina or NSTEMI
Confirmation of diagnosis of stable angina (option
at this point to escape algorithm
Medical management of stable angina
Early management of unstable angina or NSTEMI
Management of people with
low 6-month mortality risk:
• Medication
• PCI
• CABG
Stable chest pain diagnosis
Management of people with
high 6-month mortality risk
• Medication
• PCI
• CABG
Medical management of stable angina if:
• Symptoms not controlled on BB or CCB
• Both BB and CCB are contraindicated or not tolerated
• BB or CCB are contraindicated or not tolerated
PCI
Further management if symptoms do not respond to medical
treatment or revascularisation
Return to contents slide
Implementing NICE Guidance
CABG
Return to contents slide
< instructions slide
www.nice.org.uk
Check for a suspected ACS
• Check immediately if chest pain is current, or when the last episode was, particularly if in the
last 12 hours.
• Check if the chest pain may be cardiac. Consider:
– history of the pain
− any cardiovascular risk factors
− history of ischaemic heart disease and any previous treatment
− previous investigations for chest pain.
• Check if any of the following symptoms of ischaemia are present. These may indicate an ACS:
– Pain in the chest and/or other areas (for example, the arms, back or jaw) lasting longer
than15 minutes.
– Chest pain with nausea and vomiting, marked sweating or breathlessness (or a
combination of these), or with haemodynamic instability.
– New onset chest pain, or abrupt deterioration in stable angina, with recurrent pain
occurring frequently with little or no exertion and often lasting longer than 15 minutes.
• Central chest pain may not be the main symptom.
• Do not use response to glyceryl trinitrate (GTN) to make a diagnosis of ACS.
• Do not assess symptoms of an ACS differently in men and women or among different ethnic
groups.
• Advise people about seeking medical help if they have further chest pain.
• If the chest pain is non-cardiac, explain this to the person and refer for further investigation if
appropriate.
Return to slide 4 ACS suspected
Implementing NICE Guidance
www.nice.org.uk
Check for a suspected ACS
• Check immediately if chest pain is current, or when the last episode was, particularly if in the
last 12 hours.
• Check if the chest pain may be cardiac. Consider:
– history of the pain
− any cardiovascular risk factors
− history of ischaemic heart disease and any previous treatment
− previous investigations for chest pain.
• Check if any of the following symptoms of ischaemia are present. These may indicate an ACS:
– Pain in the chest and/or other areas (for example, the arms, back or jaw) lasting longer
than15 minutes.
– Chest pain with nausea and vomiting, marked sweating or breathlessness (or a
combination of these), or with haemodynamic instability.
– New onset chest pain, or abrupt deterioration in stable angina, with recurrent pain
occurring frequently with little or no exertion and often lasting longer than 15 minutes.
• Central chest pain may not be the main symptom.
• Do not use response to glyceryl trinitrate (GTN) to make a diagnosis of ACS.
• Do not assess symptoms of an ACS differently in men and women or among different ethnic
groups.
• Advise people about seeking medical help if they have further chest pain.
• If the chest pain is non-cardiac, explain this to the person and refer for further investigation if
appropriate.
Return to diagnostic criteria
Implementing NICE Guidance
www.nice.org.uk