Assessing the implications of implementing the NICE guideline 95 for evaluation of stable chest pain of recent onset: a single centre experience

Abstract

Prompt and accurate assessment of patients with chest pain likely of cardiac origin (of recent onset) is important and requires excellent coordination between the specialist cardiology services with general/emergency medicine and primary care physicians. The presence of clear guidelines helps streamline this process for all stakeholders, to meet the requirements set out in with the National Service Framework for managing coronary artery disease (CAD). However, the new guidance offered by NICE guideline 95 (March 2010)(1) for evaluation of patients in England and Wales with chest pain of recent onset, represent several major changes to its former guideline (NICE TA 73), and the Scottish Intercollegiate Guidelines Network (SIGN) guideline 96 (2007, which is based on recommendations from European Society of Cardiology(2)) currently guiding the management of such patient in Scotland. This is likely to cause confusion and lack of uniformity in assessing patients across the United Kingdom. We evaluated what change of practices and services that may be necessary, if the recommendations of this NICE guideline 95 were accommodated or adopted by SIGN, in a Rapid Access Chest Pain Clinic (RACPC) setting in a medium sized teaching hospital in Scotland, United Kingdom. All patients (n = 96) evaluated with chest pain of recent onset in the RACPC at Ninewells Hospital for two consecutive calendar months (January, February 2010, i.e. immediately prior to issue of the NICE guideline 95) were included in this analysis. The study design was retrospective review of case notes. The investigations currently offered and their outcomes were recorded and contrasted with outcomes if the new NICE guidelines were adopted, based on the NICE guidance to calculate Pre-test likelihood of presence of significant coronary artery disease. If the NICE guidance on chest pain of recent onset had been implemented in our study population, a significant change in the offer of specialist cardiac investigations may have been required at the initial clinical assessment. This includes a 42.7% increase in offer of invasive coronary angiography, 24.0% increase in functional imaging, 8.3% increase in CT calcium scoring as the initial test of choice, in lieu of a 74.1% reduction of offer of exercise tolerance tests. If the NICE guidance on chest pain of recent onset had been implemented in our study population, the need for change of the offer of specific first line tests (as discussed above) means that, a major re-organisation in both the services in RACPCs and the current process of referral to these specialists cardiac services from the primary care physicians will be required. Whilst acknowledging that regional variations may exist in the proportions of tests needed (depending on the incidence and prevalence of CAD and risk factors), these figures from our study represent a much higher level of need of these specialist tests for patients attending RACPCs than initially suggested by contemporary reviews. We therefore conclude that data from larger studies in many regions may be useful for understanding the degree of regional and national changes required for organising the structure and referrals to specialist cardiac services in Scotland, if an equitable service based on NICE guidance 95 is rolled out throughout United Kingdom in future.