Quality statement 4: Coronary angiography and PCI for adults with NSTEMI or unstable angina who are clinically unstable

Quality statement

Adults with non-ST-segment-elevation myocardial infarction (NSTEMI) or unstable angina who are clinically unstable have coronary angiography (with follow-on percutaneous coronary intervention [PCI] if indicated) as soon as possible, but within 24 hours of becoming clinically unstable.

Rationale

Coronary angiography is important to define the extent and severity of coronary disease. The benefits of an early invasive strategy appear to be greatest in people at higher risk of future adverse cardiovascular events. In people with NSTEMI or unstable angina who are clinically unstable, coronary angiography (with follow-on PCI if indicated) should be done as soon as possible so that appropriate treatment can be given. It may reduce lengthy hospital stays and prevent further cardiovascular events in both the short and long term. The timing of coronary angiography will be different for each person, but should be within 24 hours of becoming clinically unstable.

Quality measures

Structure

Evidence of local arrangements to ensure that adults with NSTEMI or unstable angina who are clinically unstable have coronary angiography (with follow-on PCI if indicated) as soon as possible, but within 24 hours of becoming clinically unstable.

Data source: Local data collection.

Process

a) Length of time taken for adults with NSTEMI or unstable angina who are clinically unstable (on admission or during their hospital stay) to receive coronary angiography (with follow-on PCI if indicated).

Local areas should collaborate with healthcare professionals to determine if the timeframe was appropriate for the patient.

Data source: Local data collection.

b) Proportion of adults with NSTEMI or unstable angina who are clinically unstable who receive coronary angiography (with follow-on PCI if indicated) within 24 hours of becoming clinically unstable.

Numerator – the number in the denominator receiving coronary angiography (with follow-on PCI if indicated) within 24 hours of becoming clinically unstable.

Denominator – the number of adults with NSTEMI or unstable angina who are clinically unstable.

Outcome

Incidence of cardiovascular events.

Data source: Local data collection.

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

Service providers (secondary care and cardiac service providers) ensure that local pathways are in place for adults with NSTEMI or unstable angina who are clinically unstable to be offered coronary angiography (with follow-on PCI if indicated) as soon as possible but within 24 hours of becoming clinically unstable.

Healthcare professionals ensure that they offer adults with NSTEMI or unstable angina who are clinically unstable, coronary angiography (with follow-on PCI if indicated) as soon as possible but within 24 hours of becoming clinically unstable.

Commissioners (clinical commissioning groups) ensure that they commission services with the capacity and expertise for adults with NSTEMI or unstable angina who are clinically unstable to be offered coronary angiography (with follow-on PCI if indicated) as soon as possible but within 24 hours of becoming clinically unstable.

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

Adults with heart conditions called NSTEMI and unstable angina and whose condition is unstable are offered a test called coronary angiography and treatment to improve blood flow to the heart if needed, as soon as possible but within 24 hours of their condition becoming unstable.

Source guidance

  • Unstable angina and NSTEMI (NICE clinical guideline 94) recommendation 1.5.1 [the timeframe of 24 hours is based on consensus of expert opinion].

Definitions of terms used in this quality statement

Clinically unstable

People who are clinically unstable are defined as those with:

  • ongoing or recurring pain despite treatment

  • haemodynamic instability (low blood pressure, shock)

  • dynamic ECG changes

  • left ventricular failure.

[Expert opinion]

As soon as possible

Local areas should collaborate with healthcare professionals to determine the appropriate timeframes for patients. [Expert opinion]