2019 surveillance of chest pain of recent onset: assessment and diagnosis (NICE CG95)

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:

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:

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:

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.