(Do Not Delete This Slide) : Algorithm Map

Presenters Notes
[Do not delete this slide]

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Implementing NICE Guidance www.nice.org.uk

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 algor

ithm Stable chest pain algorithm
(including diagnosis of stable chest pain and

management of stable angina)
(including diagnosis of acute chest pain and
A B
management of unstable angina and
NSTEMI)
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 www.nice.org.uk 3

People presenting with acute chest pain
Acute coronary syndrome (ACS)
suspected?
Yes No
(checking for suspected ACS)
• Start management immediately Consider other causes of chest

(box 1) pain, including potentially life-
• Do not delay transfer to hospital threatening ones
• Current chest pain or

• Recent ACS and further chest pain No current chest pain
develops
Refer to hospital for assessment as an emergency
Shortcut to Initial assessment < slide 3 Contents

Acute chest pain – referral to hospital
No current chest pain
• Chest pain more than 72 hours ago

Chest pain in the last 12 hours
• No complications
or
or
Chest pain 12–72 hours ago
Signs of complications e.g. pulmonary oed
ema
A B
Both boxes recommend an initial assessment

Click here to move to initial assessment C < slide 4 ACS suspected?

Acute chest pain – referral to hospital
• Chest pain more than 72 hours

ago Signs of complications e.g.
• No complications pulmonary oedema
Carry out an assessment. Decide if Decide if referral should be:

referral is: • as an emergency
• necessary or
• urgent • for urgent same-day assessment
Return to slide 5 No current chest pain

Acute chest pain – Referral to hospital
Chest pain in the last 12 hours Chest pain 12–72 hours ago
Resting 12-lead ECG • Resting 12-lead ECG

abnormal or unavailable normal
• No reasons for emergency
Refer to hospital for Refer to hospital for urgent same-day

assessment as an assessment
emergency
Return to slide 5 No current chest pain

Acute chest pain – in hospital
Initial assessment
(see box 3)
ECG findings Troponin levels
• Regional ST-segment If initial troponin is raised:

elevation or •consider other causes e.g. myocarditis, aortic
• Presumed new left bundle dissection or pulmonary embolism
branch block (LBBB)? •follow local protocols for STEMI or NICE clinical
guideline on unstable angina and NSTEMI
•continue monitoring (box 2)
Yes / No Repeat troponin 10–12 hours after onset of

symptoms
Shortcut to management of unstable angina and NSTEMI

• Regional ST-segment elevation or

• Presumed LBBB?
Yes No
Follow local protocols for ST-segment-

Regional ST-segment depression or deep
elevation myocardial infarction (STEMI)
T wave inversion suggestive of NSTEMI
until firm diagnosis made
or unstable angina?
Continue monitoring (box 2)
A
Yes B No C
Move to Diagnosis D < slide 8 Initial assessment

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 el Shortcut to

evation or presumed LBBB management of unstable angina and NSTE
MI
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 elev Shortcut to

ation or presumed LBBB management of unstable angina and NS
TEMI
Acute chest pain – diagnosis
Diagnostic criteria met? (box 4)
Yes No Uncertain
Continue
Treat according to • Reassess
monitoring (
local protocols for • If myocardial ischaemia suspected,
box 2)
STEMI or NICE see diagnosis of stable chest pain A
management of unsta • Use clinical judgement to decide on
ble angina / NSTEMI timing of further investigations
C
B
End of acute chest pain diagnosis algorithm. < slide 9 Regional ST-segment
Shortcut to contents page elevation or presumed LBBB?
Shortcut to algorithm close: Shortcut to

Find out more and tell us what you think diagnosis of stable chest pain

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
< slide 12 the end of the acute chest

Continue pain diagnosis algorithm

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 events 1. Assess bleeding risk (see box 11)
and pertinent comorbidity before considering treatments and at each stage of
management
• Lowest risk (≤ 1.5%)2 • Intermediate risk (> 3.0–6.0%)2

• Low risk (> 1.5–3.0%)2 A • High risk (> 6.0–9.0%)2
• Highest risk (> 9.0%)2
B
Hyperlink to online GRACE calculator

(not endorsed by NICE)

Low risk
(> 1.5–3.0%)1
Lowest risk (≤ 1.5%)1
Offer clopidogrel as a treatment option for up to

Initial conservative management 12 months to people who have had an NSTEMI,
regardless of treatment
Recurrent spontaneous
ischaemia? Yes
No
Coronary
Consider ischaemia testing angiography Discuss managem
Yes ent with interven
tional cardiologist
and cardiac surg
Conservative eon
Ischaemia demonstrated?
No management

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 Percutaneous coronary

intervention (PCI Coronary artery bypass
management grafting (CABG)
)
A B C
Return to slide 14 containing risk

< slide 15 Low and lowest risk classifications D

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

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

Intermediate risk High risk Highest risk

(> 3.0–6.0%)1 (> 6.0–9.0%)1 (> 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

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

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
Percutaneous coronary Coronary artery bypass
management intervention (PCI) grafting (CABG)
A B C
End of unstable angina/NSTEMI algorithm return t

o the contents slide D
Shortcut to algorithm close: < slide 19 Intermediate,
Find out more and tell us what you think high and highest risk

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

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

People presenting with stable chest pain
Carry out a clinical assessment (box 5) A
• Does the person have • Does the person have

Does the person
non-anginal chest pain features of typical or
have confirmed
and atypical angina and
coronary artery
• Stable angina is not • Is stable angina suspected
disease (CAD)1?
suspected based on based on history and risk
history and risk factors? ( factors? (box 6)
box 6)
E
C
Yes Yes Yes

B D F
< slide 3 contents

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

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 Return to slide 24 Clinical assessment

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 mo

re than 90%
Estimated likelihood and Estimated likeliho
of CAD is less than od of CAD is 10–9
10% • Person has features of typical ang 0%
ina
A C
B
< slide 24 Clinical assessment

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 a Return to slide 27 Stable angina is suspected
ngina
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

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 es Diagnostic testing when es Diagnostic testing when es

timated likelihood of CADAi timated likelihood of CAD i timated likelihood of CAD
s 10–29% s 30–60% B C
is 61-90%
Move to management of stable angina D < slide 27 Stable angina suspected

Stable chest pain – diagnostic testing
Offer CT calcium scoring
If score is 0: investigate If score is 1–400: If score is > 400: follow

other causes of chest offer 64-slice (or above) CT pathway for
pain1 coronary angiography 61–90% CAD
Significant CAD? (box 9)
Yes / No / Uncertain
Shortcut to 61-90% likelihood of CAD

Uncertain Yes No
Offer non-invasive functional imaging ( Investigate other
Treat as stable
box 8) causes of chest
angina
pain1
Reversible myocardial ischaemia?
Yes No
Treat as stable Investigate other causes
angina of chest pain1
Return to slide 30 containing all risk classifications

< slide 28 Likelihood
Shortcut to management of stable angina of CAD 10–29%

Stable chest pain – Estimated likelihood of CAD is 30–60%
diagnostic testing
Offer non-invasive functional imaging (box 8)

Yes
Uncertain No
Offer invasive coronary Investigate other causes
Treat as stable angina
angiography of chest pain1
Yes No
Treat as stable angina Investigate other causes

of chest pain1
Shortcut to
Return to slide 30 containing all risk classifications management of stable an
gina
Is invasive coronary angiography appropriate and

acceptable and is coronary revascularisation
being considered?
No Yes
A B
< slide 30 Estimated likelihood of CAD 10–90%

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)
No Yes
Investigate other causes of chest pain1 Treat as stable angina
Return to slide 34 Estimated lik

elihood of CAD 61–90% Shortcut to management of stable angina

Stable chest Likelihood of CAD is 61–90% and invasive coronary
pain – angiography is appropriate and acceptable and coronary
revascularisation is being considered
diagnostic
testing Offer invasive coronary angiography

Yes Uncertain No
Treat as stable Offer non-invasive Investigate other

angina functional imaging (box 8) causes of chest pain1
Yes No
Return to slide 30 Estimated likelihood 10-90%
End of stable chest pain diagnosis algorithm. Shortcut to

Shortcut to return to contents page management of stable angi
na
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 No
Shortcut to diagnosis of stable chest pain < slide 30 estimated likelihood of CAD 10−90%

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?’

Stable angina
Symptoms are not satisfactorily controlled or medication

is not tolerated?
BB or CCB tolerated but CCB or BB is contrai

symptoms not controlle Both BB and CCB are contr ndicated or not tol
d aindicated or not tolerated erated
A B C
If stable angina does not respond to drug treatment and/or revascularisation D

Stable angina
If a calcium channel blocker is If a beta blocker is contraindicated or
contraindicated or not tolerated, consider not tolerated, consider a calcium
a beta blocker C 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 anti-
anginal 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? < slide 37 stable angina diagnosed

Stable angina
Medical management of stable

angina. Are symptoms
satisfactorily controlled?
Yes A No B
Return to slide 39 Combinations of drug treatments

Stable angina

•Discuss:
disease
–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

?
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 needed 1.
•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:
ohave 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?

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 anti-
anginal 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

Stable angina

Yes A No B
Return to slide 39- Combinations of drug treatments

Stable angina

•Discuss:
disease
–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.

Stable angina

–that for people with anatomically less complex disease who do not have a

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?

Stable angina

Yes A No B
Return to slide 39 combinations of drug treatments

Stable angina

•Discuss:
disease
–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

Stable angina

–that for people with anatomically less complex disease who do not have a
Return to slide 49 – Are symptoms satisfactorily controlled

?
Stable angina
• If stable angina does not respond to drug treatment and/or revascularisation, re-
evaluate. 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 < slide 37 management of stable angina

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

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

•Include:
–heart rhythm
< slide 8 Initial assessment

•Include:
–heart rhythm
< slide 9 ST-segment elevation and new LBBB

•Include:
–heart rhythm
< slide 10 yes ST-segment depression or T wave inversion

•Include:
–heart rhythm
< slide 11 no ST-segment depression or T wave inversion

•Include:
–heart rhythm
< slide 12 diagnostic criteria

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

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

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

•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.
– increasing age
< slide 25 non-anginal chest pain

•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.
– increasing age
< slide 27 stable angina suspected

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

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

•Offer1:
and preferences.
•Do not use:
< slide 32 significant CAD

•Offer1:
•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 exercise or dobutamine for stress echocardiography or MR imaging for
stress-induced wall motion abnormalities.
•Do not use:
–exercise ECG to diagnose or exclude stable angina in people without known
CAD.
< slide 33 likelihood of CAD 30−60%

•Offer1:
and preferences.
•Do not use:
< slide 35 invasive coronary angiography not appropriate

•Offer1:
and preferences.
•Do not use:
< slide 36 invasive coronary angiography is appropriate

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





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

Box 11 – Factors associated with high bleeding risk
•Advancing age
•Known bleeding complications
•Renal impairment
•Low body weight
< slide 13 unstable angina/NSTEMI

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

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.

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.

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.

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

approach to assess severity and complexity of coronary disease and other
relevant clinical factors and comorbidities.

coronary anatomy, extent of stenting required or other relevant clinical factors
or comorbidities.
•The multidisciplinary team should include interventional cardiologists and

cardiac surgeons.

approach to assess severity and complexity of coronary disease and other relevant
clinical factors and comorbidities.

coronary anatomy, extent of stenting required or other relevant clinical factors or
comorbidities.
•The multidisciplinary team should include interventional cardiologists and cardiac

surgeons.

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.


disease.


disease.

< slide 27 stable angina is suspected

Find out more and tell us what you
think
Next slide

Find out more – Unstable angina and
NSTEMI guideline
Visit www.nice.org.uk/guidance/CG94 for:

• the guideline
• the quick reference guide
• ‘Understanding NICE guidance’
• slide set
• costing statement
• audit support, including patient questionnaire
• online educational tool
Next slide

Find out more – Chest pain of recent
onset guideline
• the guideline
• slide set
• costing report and template
• audit support
• implementation advice
• online educational tool
• referral checklist
• calcium scoring factsheet
Next slide

Find out more – Stable angina
guideline
• the guideline
• slide set
• costing statement
• audit support
• baseline assessment tool
• factsheet on revascularisation for stable angina
Next slide

Find out more – related guidance
Visit www.nice.org.uk for guidance on:

• Stable angina quality standard
• New generation cardiac CT scanners
• Hypertension
• Management of hyperglycaemia in patients with ACS
• Chronic heart failure
• Ticagrelor
• Prasugrel
• Lipid modification
• MI: secondary prevention
Next slide

What do you think?
Did the implementation tool you accessed today meet your

requirements, and will it help you to put the NICE guidance
into practice?
We value your opinion and are looking for ways to improve
our tools. Please complete this short evaluation form.
If you are experiencing problems accessing or using this
tool, please email implementation@nice.org.uk
To open the links in this slide set right click over the link
and choose ‘open link’
Shortcut to contents page

Recent acute chest pain diagnosis Contents slide Stable chest pain diagnosis
Clinical assessment:
Acute coronary syndrome No current chest pain
• Confirmed CAD
suspected – management – management and
• Non-anginal chest pain – stable angina not suspected
and referral referral
• Stable angina suspected
Acute chest pain assessment: Diagnosis of stable angina in people with suspected stable angina
• ECG findings when estimated likelihood of coronary artery disease:
• Tropinin results - is more than 90% - is less than 10% - is 10−90%
Further diagnostic testing of people with suspected stable

Diagnosis in people with acute chest pain angina and estimated likelihood of CAD of:
- 10–29% - 30–60% - 61–90%
Diagnosis of unstable angina or NSTEMI confirmed (option at
this point to escape algorithm) Confirmation of diagnosis of stable angina (option
at this point to escape algorithm
Management of unstable angina or NSTEMI Medical management of stable angina
Early management of unstable angina or NSTEMI Medical management of stable angina if:
• Symptoms not controlled on BB or CCB
• Both BB and CCB are contraindicated or not tolerated
Management of people with Management of people with • BB or CCB are contraindicated or not tolerated
low 6-month mortality risk: high 6-month mortality risk
• Medication • Medication PCI CABG
• PCI • PCI
• CABG • CABG Further management if symptoms do not respond to medical
treatment or revascularisation
Return to contents slide Return to contents slide
Implementing NICE Guidance < 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

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

(Do Not Delete This Slide) : Algorithm Map

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[Do not delete this slide]

Implementing NICE Guidance www.nice.org.uk

Recent acute chest pain algor

(including diagnosis of stable chest pain and

Shortcut to diagnosis of acute chest pain

Shortcut to management of unstable angina and NSTEMI

Shortcut to management of stable angina

Implementing NICE Guidance www.nice.org.uk 3

• Start management immediately Consider other causes of chest

• Current chest pain or

Refer to hospital for assessment as an emergency

Shortcut to Initial assessment < slide 3 Contents

Implementing NICE Guidance www.nice.org.uk 4

No current chest pain

• Chest pain more than 72 hours ago

Both boxes recommend an initial assessment

Implementing NICE Guidance www.nice.org.uk 5

• Chest pain more than 72 hours

Carry out an assessment. Decide if Decide if referral should be:

Return to slide 5 No current chest pain

Implementing NICE Guidance www.nice.org.uk 6

Resting 12-lead ECG • Resting 12-lead ECG

Refer to hospital for Refer to hospital for urgent same-day

Return to slide 5 No current chest pain

Implementing NICE Guidance www.nice.org.uk 7

• Regional ST-segment If initial troponin is raised:

Yes / No Repeat troponin 10–12 hours after onset of

Shortcut to management of unstable angina and NSTEMI

Implementing NICE Guidance www.nice.org.uk 8

• Regional ST-segment elevation or

Follow local protocols for ST-segment-

Implementing NICE Guidance www.nice.org.uk 9

The person has regional ST-segment

• Follow NICE clinical guideline on unstable angina and

Return to slide 9 Regional ST-segment el Shortcut to

Return to slide 9 Regional ST-segment elev Shortcut to

Diagnostic criteria met? (box 4)

Shortcut to algorithm close: Shortcut to

Implementing NICE Guidance www.nice.org.uk 12

< slide 12 the end of the acute chest

Implementing NICE Guidance www.nice.org.uk 13

• Lowest risk (≤ 1.5%)2 • Intermediate risk (> 3.0–6.0%)2

Hyperlink to online GRACE calculator

Implementing NICE Guidance www.nice.org.uk 14

Offer clopidogrel as a treatment option for up to

Implementing NICE Guidance www.nice.org.uk 15

Discuss management with cardiologist and cardiac surgeons. Consider

Conservative Percutaneous coronary

Return to slide 14 containing risk

Implementing NICE Guidance www.nice.org.uk 16

Percutaneous coronary intervention (PCI)

Return to slide 16 Discuss management

Implementing NICE Guidance www.nice.org.uk 17

Coronary artery bypass grafting (CABG)

Return to slide 16 Discuss management

Implementing NICE Guidance www.nice.org.uk 18

Intermediate risk High risk Highest risk

Implementing NICE Guidance www.nice.org.uk 19

Management of intermediate risk, high risk

Discuss management strategy with interventional cardiologist and cardiac surgeon.

< slide 19 intermediate, high and highest risk

Implementing NICE Guidance www.nice.org.uk 20