Update information

New recommendations have been added for the assessment and diagnosis of acute chest pain and the assessment and diagnosis of stable chest pain.

These are marked as:

  • [new 2016] if the evidence has been reviewed and the recommendation has been added or updated

  • [2016] if the evidence has been reviewed but no change has been made to the recommended action.

Where recommendations end [2010], the evidence has not been reviewed since the original guideline.

Recommendations that have been changed

Amended recommendation wording (change to meaning)

Recommendation in 2010 guideline

Recommendation in current guideline

Reason for change

Take a resting 12-lead ECG and a blood sample for troponin I or T measurement (see section 1.2.5) on arrival in hospital. (1.2.4.1)

Take a resting 12-lead ECG and a blood sample for high-sensitivity troponin I or T measurement (see section 1.2.5) on arrival in hospital. (1.2.4.1)

Updated to clarify the use of high-sensitivity troponin testing.

Take into account the clinical presentation, the time from onset of symptoms and the resting 12-lead ECG findings when interpreting high sensitivity troponin measurements. (1.2.5.5)

When interpreting high-sensitivity troponin measurements, take into account:

  • the clinical presentation

  • the time from onset of symptoms

  • the resting 12-lead ECG findings

  • the pre-test probability of NSTEMI

  • the length of time since the suspected ACS

  • the probability of chronically elevated troponin levels in some people

  • that 99th percentile thresholds for troponin I and T may differ between the sexes. (1.2.5.7)

Updated to clarify the use of high-sensitivity troponin testing.

When diagnosing MI, use the universal definition of myocardial infarction [2]. This is the 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

  • new or presumed new significant ST-segment-T wave (ST‑T) changes or new left bundle branch block (LBBB).

  • development of pathological Q waves in the ECG.

  • imaging evidence of new loss of viable myocardium or new regional wall motion abnormality.

  • identification of an intracoronary thrombus by angiography or autopsy. (1.2.6.1)

When diagnosing MI, use the universal definition of myocardial infarction. This is the detection of rise and/or fall of cardiac biomarkers values [preferably cardiac troponin (cTn)] with at least one value above the 99th percentile of the upper reference limit with at least one of the following:

  • symptoms of ischaemia

  • new or presumed new significant ST-segment-T wave (ST‑T) changes or new left bundle branch block (LBBB)

  • development of pathological Q waves in the ECG

  • imaging evidence of new loss of viable myocardium or new regional wall motion abnormality

  • identification of an intracoronary thrombus by angiography. (1.2.6.1)

Updated reference to universal definition of MI and removal of the reference to autopsy as a diagnostic criterion in this context.

Reassess people with chest pain without raised troponin levels (determined from appropriately timed samples) and no acute resting 12-lead ECG changes to determine whether their chest pain is likely to be cardiac.

If myocardial ischaemia is suspected, follow the recommendations on stable chest pain in this guideline (see section 1.3). Use clinical judgement to decide on the timing of any further diagnostic investigations. (1.2.6.5)

Reassess people with chest pain without raised troponin levels and no acute resting 12-lead ECG changes to determine whether their chest pain is likely to be cardiac.

If myocardial ischaemia is suspected, follow the recommendations on stable chest pain in this guideline (see section 1.3). Use clinical judgement to decide on the timing of any further diagnostic investigations. (1.2.6.5)

Amended to align with new recommendation 1.2.5.3, which suggests that a single test may be used for rule out.

Anginal pain is:

  • constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms

  • precipitated by physical exertion

  • relieved by rest or GTN within about 5 minutes.

Use clinical assessment and the typicality of anginal pain features listed below to estimate the likelihood of CAD (see table 1):

  • Three of the features above are defined as typical angina.

  • Two of the three features above are defined as atypical angina.

  • One or none of the features above are defined as non-anginal chest pain. (1.3.3.1)

Assess the typicality of chest pain as follows:

  • Presence of three of the features below is defined as typical angina.

  • Presence of two of the three features below is defined as atypical angina.

  • Presence of one or none of the features below is defined as non-anginal chest pain.

Anginal pain is:

  • constricting discomfort in the front of the chest, or in the neck, shoulders, jaw, or arms

  • precipitated by physical exertion

  • relieved by rest or GTN within about 5 minutes. (1.3.3.1)

Amended to remove reference to estimate of likelihood of CAD and reorganised to clarify.

Consider investigating other causes of angina, such as hypertrophic cardiomyopathy, in people with typical angina-like chest pain and a low likelihood of CAD (estimated at less than 10%). (1.3.3.8)

Consider investigating other causes of angina, such as hypertrophic cardiomyopathy, in people with typical angina-like chest pain and a low likelihood of CAD. (1.3.3.6)

Amended to remove numerical estimate of CAD likelihood.

For people in whom stable angina cannot be diagnosed or excluded on the basis of the clinical assessment alone, take a resting 12-lead ECG as soon as possible after presentation. (1.3.3.12)

For people in whom stable angina cannot be excluded on the basis of the clinical assessment alone, take a resting 12-lead ECG as soon as possible after presentation. (1.3.3.10)

Amended to align with new recommendations 1.3.1.1 and 1.3.1.2, which indicate that stable angina can only be excluded by clinical assessment. Diagnosis needs additional testing.

For people with confirmed CAD (for example, previous MI, revascularisation, previous angiography) in whom stable angina cannot be diagnosed or excluded based on clinical assessment alone, see recommendation 1.3.4.4 about functional testing. (1.3.3.15)

For people with confirmed CAD (for example, previous MI, revascularisation, previous angiography) in whom stable angina cannot be excluded based on clinical assessment alone, see recommendation 1.3.4.4 about functional testing. (1.3.3.14)

Amended to align with new recommendations 1.3.1.1 and 1.3.1.2, which indicate that stable angina can only be excluded by clinical assessment. Diagnosis needs additional testing.

Include the typicality of anginal pain features and the estimate of CAD likelihood (see recommendation 1.3.3.16) in all requests for diagnostic investigations and in the person's notes. (1.3.4.1)

Include the typicality of anginal pain features (see recommendation 1.3.3.1) in all requests for diagnostic investigations and in the person's notes. (1.3.4.1)

Amended to remove reference to estimate of likelihood of CAD.

ISBN: 978-1-4731-2182-9

  • National Institute for Health and Care Excellence (NICE)