L. Bryan's research while affiliated with Chelsea and Westminster Hospital NHS Foundation Trust and other places

Objective To describe the clinical outcomes of patients for whom National Institute for Health and Care Excellence (NICE) recent-onset chest pain guidance would not have recommended further investigation, compared with those of patients where further investigation would have been recommended. Methods 557 consecutive patients with recent-onset chest pain attending rapid-access chest pain clinics (RACPC) in two district general hospitals over a 9-month period were retrospectively reviewed. Likelihood of coronary artery disease (CAD) was calculated according to NICE-defined modified Diamond–Forrester criteria. Patients were categorised into those for whom NICE guidelines recommend (NICE-Y) and do not recommend (NICE-N) further investigation. Main outcome measures were subsequent diagnosis of significant CAD and major adverse cardiac events (MACE) at 6 months. Results 187/557 (33.6%) patients comprised NICE-Y group, with 370/557 (66.4%) in NICE-N group. 360/370 (97.3%) of NICE-N group would have been excluded from further investigation due to non-anginal chest pain. Of 92/557 (16.5%) patients subsequently diagnosed with significant CAD, 35/557 (9.5%) were from NICE-N group versus 57/557 (30.5%, p<0.0001) from NICE-Y group. Of 11 patients experiencing at least one MACE, 7/557 (1.9%) were from NICE-N group, versus 4/557 (2.1%, p=1.000) from NICE-Y group. Conclusions The rigid application of NICE chest pain guidance to a RACPC population may result in up to two-thirds of patients being excluded from further cardiac investigation. Potentially, up to 10% of these patients may subsequently be diagnosed with significant CAD, with up to 2% potentially experiencing a major adverse cardiac event.

Introduction NICE guidance for the investigation of chest pain of recent onset1 recommends clinical assessment and risk stratification within a diagnostic algorithm. Patients with pain considered “non-anginal”, and those with atypical/typical anginal pain but a likelihood of coronary artery disease (CAD) <10% are not routinely recommended for cardiac investigation. This study sought to assess whether clinical outcomes support these patients being considered at low risk of CAD. Methods 557 consecutive patients (50.4% male; median age 55 yrs) attending rapid access chest pain clinics (RACPC) at two hospitals were risk stratified using NICE criteria. Frequency of admission with suspected angina, diagnosis of CAD and incidence of major adverse cardiac events (MACE: myocardial infarction (MI), cerebrovascular accident (CVA), emergency revascularisation or cardiac-related death) were compared for all risk categories at 6 months. Results Of 360/557 patients with “non-anginal” pain, 14 (3.9%) were subsequently admitted with angina, 34 (9.4%) were diagnosed with CAD, 3 (0.8%) with MI and 2 (0.6%) with CVA. This group accounted for 36.9% of all patients diagnosed with CAD and 38.5% of all patients with MACE. Of 10/557 patients with atypical/typical anginal pain and a likelihood of CAD <10%, 1 (10%) was diagnosed with CAD. None were admitted with angina or diagnosed with MACE. This group accounted for 1.1% of all patients diagnosed with CAD. Conclusions This study suggests one in ten patients routinely excluded from cardiac investigation by the NICE algorithm have CAD and just over one in a hundred of them have a MACE episode. Although these patients are considered low risk, they account for one third of adverse cardiac events in patients attending RACPC.

ARTICLE Sir, We thank George and Chattopadhyay for their detailed appraisal1 of our recent paper,2 and we note with interest their extensive references to our data in their recent publication.3 While they raise some interesting issues, we dispute a number of their assertions. To address their points in turn: 1. The study determines the likelihood of CAD in all subjects, at odds with guidance. We agree that it would have been ideal to exclude patients with known coronary artery disease (CAD) from further assessment in our study; however, the reasons for not doing so were multiple and compelling. The foremost issue was how to define CAD to generate an appropriate exclusion criterion. Traditionally, significant CAD has been defined by a history of myocardial infarction, ‘positive’ angiography or coronary revascularization. With advancing biomarker technology (e.g. highly sensitive troponin) and radiological techniques (e.g. cardiac computed tomography), detection of early CAD may now precede the development of symptoms and there is debate as to the implications of these occult findings. Enhanced diagnostic sensitivity for ischemic myocardial injury may also come at the expense of specificity, especially …

The Royal College of Physicians report Acute medical care: the right person, in the right setting--first time advocates the introduction of a standardised NHS Early Warning Score (NEWS). Recommendations for the optimum scoring system have been released by NHS Quality Improvement Scotland (NHS QIS) and the National Institute for Health and Clinical Excellence (NICE). This study reviewed clinical practice in London and Scotland against national guidelines. All hospitals responsible for acute medical admissions completed a telephone survey (n = 25 London; n = 23 Scotland). All used an early warning system at point of entry to care. Eleven different systems were used in London and five in Scotland. Forty per cent of London hospitals and 70% of Scottish hospitals incorporated the minimum data set recommended by NICE. Overall, Scotland was closer to achieving standardisation. If NEWS is implemented, consideration of the NHS QIS approach may support a more consistent response.

Background: Cardiac computed tomography (CCT) is a non-invasive imaging technique for the diagnosis of coronary artery disease (CAD). The National Institute for Health and Clinical Excellence (NICE) recommend CCT for selected patients in the assessment of chest pain of recent onset. Aims: To assess the feasibility and utility of CCT in a nurse-led, protocol-based assessment of chest pain. Methods: Patients admitted over 4 months with suspected angina were assessed for eligibility for CCT by a specialist nurse. Eligibility was defined by: a likelihood of CAD < 90%, no features of acute coronary syndrome, no contra-indications to the scanning process, and the ability to give written consent. An age and sex-matched historical cohort (for whom CCT was unavailable) was compared with the CCT cohort with regard to the diagnosis or exclusion of CAD at 3 months post-discharge from hospital. Results: Of 198 patients admitted, 98 were identified as eligible for CCT. Of these, 37 were recommended for alternative management on cardiologist review, 18 declined consent, 23 were unable to be scanned within 24 h prior to discharge and 14 underwent CCT. CAD was diagnosed or excluded in 14/14 patients undergoing CCT. CAD was diagnosed or excluded in 11/14 patients investigated without CCT, leaving 3/14 patients with no clear diagnosis. Conclusion: This study suggests nurses may be trained to assess patients for CCT within agreed protocols. In the UK it is likely these protocols will be based on NICE guidance. Despite potential diagnostic utility, CCT appears likely to form a small percentage of cardiac investigations undertaken.

IntroductionThe National Institute for Health and Clinical Excellence (NICE) have released guidelines for the investigation of chest pain of recent onset (1). There is concern that the guidelines will increase the burden on cardiac imaging, requiring service reconfiguration and investment (2, 3). This study was performed to assess the impact of the guidelines on outpatient cardiology services in the UK.Methods595 consecutive patients attending chest pain clinics at two hospitals over six months preceding release of the NICE guidelines (51% male; median age 55 yrs (range 22–94 yrs)) were risk stratified using NICE criteria. Preliminary cardiac investigations recommended by NICE were compared with existing clinical practice and the relative costs calculated.ResultsNICE would have recommended 443 patients (74%) for discharge without cardiac investigation, 10 (2%) for cardiac computed tomography (CCT), 69 (12%) for functional cardiac imaging and 73 (12%) for invasive coronary angiography (ICA). Relative to existing practice there would have been a trend towards reduced functional cardiac imaging (−24%; p=0.06) and increased CCT (+43%; p=0.436) but a significant increase in ICA (+508%; p

The National Institute for Health and Clinical Excellence (NICE) recently released guidelines for the investigation of chest pain of recent onset. There is no published data regarding their impact on out-patient cardiac services. This study was undertaken to assess the likelihood of coronary artery disease (CAD) in Rapid Access Chest Pain Clinic (RACPC) patients and the resultant investigation burden if NICE guidance was applied. Five hundred and ninety-five consecutive patients attending two RACPCs over 6 months preceding release of the NICE guidelines [51% male; median age 55 (range 22-94) years] were risk stratified using NICE criteria and the resultant investigations evaluated. One hundred and six (18%) patients had a likelihood of CAD <10%, 123 (21%) between 10% and 29%, 175 (29%) between 30% and 60%, 141 (24%) between 61% and 90% and 50 (8%) >90%. NICE would have recommended 443 (74%) patients for no cardiac investigation, 10 (2%) for cardiac computed tomography (CCT), 69 (12%) for functional cardiac testing and 73 (12%) for invasive angiography. Relative to existing practice, there would have been a trend towards reduced functional cardiac testing (-24%, P = 0.06), no significant change in CCT (43%, P = 0.436) and a significant increase in invasive angiography (508%, P < 0.001). The cost of investigations recommended by NICE would have been £15,881 greater than existing practice. This study suggests patients attending RACPC will have a greater likelihood of CAD than predicted by NICE. Differences between recommended investigations and existing practice will guide investment in cardiac services. Individual hospitals should assess their RACPC cohorts prior to implementing the NICE guidelines.

Cardiac computed tomography (CCT) is a well-validated investigation for the non-invasive assessment of coronary artery disease (CAD). The National Institute for Clinical Excellence (NICE) have recently released guidelines incorporating CCT into the diagnostic algorithm for chest pain of recent onset. To assess the frequency of eligibility for CCT in medical admissions with suspected cardiac chest pain using criteria defined by NICE. A retrospective, observational study, set in a teaching hospital acute medical unit. A total of 198 consecutive patients admitted over a 4-month period with suspected cardiac chest pain (57% male; mean age 63.5 years) were assessed for eligibility for CCT based on NICE guideline criteria. Of the 198 patients admitted, 65 (33%) patients were excluded by a raised troponin I or ischaemic ECG changes; 100 (51%) patients were excluded by pain categorized as non-anginal and 171 (86%) patients were excluded by a modified Diamond Forrester score outside the range 10-29%. Applying NICE criteria to this population ultimately resulted in 2 (1%) patients recommended for CCT, 12 (6%) for functional cardiac testing and 17 (9%) for invasive angiography. Applying current NICE guidelines for chest pain of recent onset to medical admissions results in a lesser uptake of CCT than functional testing and invasive angiography. If the NICE guidelines are revised to include patients with an intermediate pre-test probability of CAD, CCT may have a greater role.