2019 surveillance of chest pain of recent onset: assessment and diagnosis (NICE CG95)
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Overview of 2019 surveillance methods
NICE's surveillance team checked whether recommendations in chest pain of recent onset: assessment and diagnosis (NICE guideline CG95) remain up to date.
The surveillance process consisted of:
Feedback from topic experts via a questionnaire.
A search for new or updated Cochrane reviews.
Consideration of evidence from previous surveillance.
Examining related NICE guidance and quality standards and NIHR signals.
A search for ongoing research.
Examining the NICE event tracker for relevant ongoing and published events.
Literature searches to identify relevant evidence.
Assessing the new evidence against current recommendations to determine whether or not to update sections of the guideline, or the whole guideline.
Consulting on the proposal with stakeholders (this document).
For further details about the process and the possible update decisions that are available, see ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual.
Evidence considered in surveillance
Search and selection strategy
We searched for new evidence related to specific parts of the guideline. These areas were suggested by topic experts as the key areas to focus on for this surveillance review.
Focused searches included:
The diagnostic accuracy of high-sensitivity troponins in acute chest pain of suspected cardiac origin
Studies were eligible if they determined the diagnostic accuracy of high-sensitivity cardiac troponins in the diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI)/unstable angina in adults with acute chest pain/discomfort of suspected cardiac origin.
Cross-sectional studies and cohort studies were eligible. Studies with unclear reference standard details were excluded.
We found 7 studies in a search for studies published between 10 May 2016 and 24 April 2019.
The clinical effectiveness of high-sensitivity troponins in people with acute chest pain of suspected cardiac origin
Studies were eligible if they assessed the clinical effectiveness of high-sensitivity troponins in adults with acute chest pain of suspected cardiac origin (compared with standard cardiac troponins, any other high-sensitivity troponin assay, or no test) to identify/rapidly rule out NSTEMI/unstable angina and to improve patient outcomes.
Randomised controlled trials (RCTs) were eligible.
We found 4 studies in a search for studies published between 10 May 2016 and 24 April 2019.
The diagnostic accuracy of computed tomography angiography with fractional flow reserve in stable or acute chest pain of suspected cardiac origin.
Studies were eligible if they determined the diagnostic accuracy of coronary computed tomography angiography with fractional flow reserve (CT-FFR) in adults with stable or acute chest pain of suspected cardiac origin. Cross-sectional studies and cohort studies were eligible. Studies with unclear reference standard details were excluded. Only studies reporting per-patient analyses were included (in line with the guideline).
We found 4 studies in a search for studies published between 21 May 2015 and 18 April 2019.
(NB: The difference in the start dates for the above searches reflects the difference in the start dates for the update searches for the acute chest pain and stable chest pain sections of the guideline).
We also included:
2 relevant studies from a total of 7 identified by topic experts
10 studies identified in previous surveillance in 2014
7 studies identified as ongoing at previous surveillance in 2014 that have subsequently published
From all sources, we considered 34 studies to be relevant to the guideline.
See appendix A below for details of all evidence considered, and references.
Ongoing research
We checked for relevant ongoing research; of the ongoing studies identified, 6 studies were assessed as having the potential to change recommendations. Therefore, we plan to check the publication status regularly and evaluate the impact of the results on current recommendations as quickly as possible. These studies are:
The LoDED study – safe & rapid chest pain management (ISRCTN86184521)
UK GRACE Risk Score Intervention Study (ISRCTN29731761)
Clinical and demographic characteristics associated with delay in help-seeking behaviour in patients with Acute Coronary Syndrome (HS&DR 13/10/40)
The RAPID-CTCA trial (Rapid Assessment of Potential Ischaemic Heart Disease with CTCA) The role of early CT Coronary Angiography in the evaluation, intervention and outcome of patients presenting to the Emergency Department with suspected or confirmed Acute Coronary Syndrome (HTA 13/04/108)
Fractional Flow Reserve Derived From Computed Tomography Coronary Angiography in the Assessment and Management of Stable Chest Pain (FORECAST) study (NCT03187639)
Evaluating Fractional Flow Reserve computed from Cardiac CT images (ISRCTN11449939)
Intelligence gathered during surveillance
Views of topic experts
We considered the views of topic experts who were recruited to the NICE Centre for Guidelines Expert Advisers Panel to represent their specialty. For this surveillance review, topic experts completed a questionnaire about developments in evidence, policy and services related to the guideline.
We sent questionnaires to 12 topic experts and received 6 responses. Responding topic experts included consultant nurses, a general practitioner, and consultants in cardiology and cardiothoracic radiology.
The majority of topic experts did not think the guideline needed to be updated.
The topic expert feedback was used to inform the selection of the areas for focused searches.
Key points highlighted in topic expert feedback included:
Issues relating to implementation of recommendations on the use of coronary computed tomography angiography (CCTA), specifically regarding availability of suitable scanners and professionals. This feedback was included, alongside other information identified on implementation, in the summary of evidence in this surveillance review. These issues will be fed back to NICE's implementation team and will also be relayed by NICE internal processes to other key teams as appropriate.
Coronary computed tomography angiography-derived fractional flow reserve (CT-FFR) should be considered as a diagnostic approach. A focused search was performed in this surveillance review to identify any new relevant evidence in this area.
Uncertainty around the impact of high-sensitivity troponin assay use on patient outcomes. A focused search was performed in this surveillance review to identify any new relevant evidence in this area.
Need for further guidance on management of incidental findings from computed tomography (CT) scanning (e.g. lung lesions), which can be associated with anxiety in patients, and increased costs and resource use. No evidence was identified on this topic in this surveillance review.
Need for the guideline to reinforce the importance of reducing lifelong radiation dose from scanning (no further details provided). No evidence was identified on this topic in this surveillance review.
Need for further guidance on avoidance of over-investigation in patients with frailty or many comorbidities. No evidence was identified on this topic in this surveillance review.
European Society of Cardiology (ESC) guidelines i) still use pre-test probability in assessment of stable chest pain, and ii) do not recommend any specific test to diagnose chest pain (no further details provided). No evidence was identified on this topic in this surveillance review.
Implementation of the guideline
Topic expert feedback in this surveillance review emphasised difficulties in implementation of the recommendations from the 2016 guideline update on the use of CCTA in stable chest pain.
The resource impact report produced in development of this guideline noted that the availability of suitable scanners and trained professionals may affect speed of implementation and that this resource impact should be considered locally.
A statement from the British Society of Cardiovascular Imaging, which provided details on challenges in provision of CCTA, was identified in this surveillance review. Hospital Episode Statistics data for 2017/18 were also analysed to explore the delivery of CCTA for people with chest pain in hospital trusts in England (copyright © 2019, the Health and Social Care Information Centre. Re-used with the permission of the Health and Social Care Information Centre. All rights reserved). Both sources of information confirmed the geographical variation in delivery of CCTA. There is no evidence from this surveillance to suggest that CCTA should no longer be recommended as a diagnostic tool.
An adoption support resource for HeartFlow FFRCT for estimating fractional flow reserve from CCTA (NICE MTG32) has been described in the summary of evidence for this surveillance. The adoption of HeartFlow analysis for estimation of fractional flow reserve from CCTA is being supported as part of the Accelerated Access Collaborative.
The use of high-sensitivity troponin tests for early rule out of myocardial infarction, which is also within the scope of this guideline, is another technology being supported by the Accelerated Access Collaborative.
Other sources of information
We considered all other correspondence received since the guideline was published.
External correspondence was received requesting that additional guidance on diagnosis of aortic dissection be considered as part of any potential update of this guideline. Topic experts were consulted on this issue, including topic experts engaged with this surveillance review and additional experts in emergency medicine.
Nine responses were received. Of these, 3 agreed with further inclusion of aortic dissection in this guideline, 5 considered that this was not appropriate for this guideline, and 1 response was unclear.
The topic experts who considered that additional guidance on diagnosis of aortic dissection should be included in the guideline commented on the potential lethality of the condition, the need for guidance on diagnosis and immediate treatment (including follow-up of inconclusive rises in high-sensitivity troponins, and medical management of type B dissection), variation in investigation pathways and imaging availability between settings, and value of addressing clinical questions, such as the role of bedside transthoracic echocardiography for non-invasive screening, relevance of bilateral blood pressures in aortic dissection prediction, and diagnostic relevance of chest X-ray.
The topic experts who did not consider that additional guidance on diagnosis of aortic dissection should be included in this guideline noted that there was sufficient content on chest pain of suspected cardiac origin for a guideline on this area alone, that aortic dissection is a very rare differential diagnosis, and that it has a different pathology, with differences in clinical urgency and presentation, and has a different diagnostic pathway to chest pain of suspected cardiac origin once aortic syndrome was suspected. It was also commented that there are several existing non-NICE guidelines and educational resources for acute aortic syndrome, and that, if further guidance on this condition was added to this guideline, then other potential causes of chest pain may also need to be considered for inclusion.
Therefore, while views received from topic experts were mixed, the majority view was that inclusion of further guidance on aortic dissection would not be appropriate within this guideline. Furthermore, we note that several existing recommendations in this guideline specifically refer to aortic dissection (e.g. as an alternative, non-cardiac potential cause of chest pain). These specific recommendations are described more detail in Appendix A. Therefore, we do not consider there to be potential impact on recommendations in the guideline.
One topic expert in this surveillance review raised an issue with the current title of the guideline not being specific enough in terms of the population covered, i.e. chest pain suspected to be cardiac in origin. The topic expert noted that aortic dissection is an important cause of acute chest pain. It was commented that the title of the guideline should better reflect the intended content. We considered the most suitable approach to address this point, including the revision of the title to make it more specific and/or inclusion of additional explanatory text on the guidance overview page. We plan to amend the title of the guideline to reflect the content more clearly. A potential revision of the guideline title is: 'Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis.'
Views of stakeholders
Stakeholders are consulted on all surveillance reviews except if the whole guideline will be updated and replaced. Because this surveillance proposal is to not update the guideline, we are consulting with stakeholders.
See ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual for more details on our consultation processes.
Equalities
No equalities issues were identified during the surveillance process.
Editorial amendments
We received topic expert feedback in this surveillance review that the current title of the guideline is not specific enough in terms of the population covered, i.e. chest pain suspected to be cardiac in origin. We considered the most suitable approach to address this point, including the revision of the title to make it more specific and/or inclusion of additional explanatory text on the guidance overview page.
We plan to amend the title of the guideline to reflect the content more clearly. A potential revision of the guideline title is: 'Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis.'
Overall surveillance proposal
After considering all evidence and other intelligence and the impact on current recommendations, we propose that no update is necessary.
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