Quality statement 2: Risk assessment for adults with NSTEMI or unstable angina

Quality statement

Adults with non-ST-segment-elevation myocardial infarction (NSTEMI) or unstable angina are assessed for their risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality to guide clinical management.

Rationale

Assessing and categorising risk of future adverse cardiovascular events by formal risk assessment (for example, using the GRACE scoring system) in people who have been diagnosed with NSTEMI or unstable angina is important for determining early management strategies. It also allows the benefits of treatment to be balanced against the risks of treatment‑related adverse events. Failure to categorise future risk can lead to people being given inappropriate treatment.

Quality measures

Structure

Evidence of local arrangements to ensure that adults with NSTEMI or unstable angina are assessed for their risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality to guide clinical management.

Data source: Local data collection.

Process

Proportion of presentations for NSTEMI or unstable angina that had an assessment of the risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality.

Numerator – the number in the denominator that had an assessment of the risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality.

Denominator – the number of presentations because of NSTEMI or unstable angina.

Data source: Local data collection. Contained within NICE clinical guideline 94 audit support, criterion 1.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (cardiac service providers) ensure that local pathways are in place for adults with NSTEMI or unstable angina to be assessed for their risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality. Providers should also raise awareness among healthcare professionals of the importance of risk assessment in guiding clinical management.

Healthcare professionals ensure that they assess the risk of future adverse cardiovascular events in adults with NSTEMI or unstable angina using an established risk scoring system that predicts 6-month mortality to guide clinical management.

Commissioners (clinical commissioning groups) ensure that they commission services with staff with the expertise to assess the risk of future adverse cardiovascular events in adults with NSTEMI or unstable angina using established risk scoring systems that predict 6-month mortality to guide clinical management.

What the quality statement means for patients, service users and carers

Adults with heart conditions called NSTEMI and unstable angina have their risk of another heart attack estimated to guide their treatment.

Source guidance

Definitions of terms used in this quality statement

Assessment for risk of future adverse cardiovascular events

Individual risk of future adverse cardiovascular events should be formally assessed using an established risk scoring system that predicts 6-month mortality (for example, Global Registry of Acute Cardiac Events [GRACE]).

The formal risk assessment should include:

  • a full clinical history (including age, previous myocardial infarction and previous percutaneous coronary intervention or coronary artery bypass grafting)

  • a physical examination (including measurement of blood pressure and heart rate)

  • resting 12-lead ECG (looking particularly for dynamic or unstable patterns that indicate myocardial ischaemia)

  • blood tests (such as troponin I or T, creatinine, glucose and haemoglobin).

[NICE clinical guideline 94, recommendations 1.2.1 and 1.2.2]

Categories for risk of future adverse cardiovascular events

Using 6-month mortality, the categories for the risk of future adverse cardiovascular events are:

Predicted 6-month mortality

Risk of future adverse cardiovascular events

1.5% or below

Lowest

>1.5 to 3.0%

Low

>3.0 to 6.0%

Intermediate

>6.0 to 9.0%

High

Over 9.0%

Highest

[NICE clinical guideline 94, recommendation 1.2.5]