Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis

Reasons for the decision

Topic experts suggested key areas to focus on in this surveillance review, including the use of coronary computed tomography angiography-derived fractional flow reserve (CT-FFR) and high-sensitivity troponins. Focused searches for new evidence were undertaken in these areas as part of this surveillance. The new evidence that was identified was not considered to impact on the recommendations in this guideline.

We identified ongoing research on high-sensitivity troponins, the GRACE risk score, delay in help-seeking behaviour for acute coronary syndrome (ACS), coronary computed tomography angiography (CCTA) in suspected or confirmed ACS, and CT-FFR. The publication status of these studies and any potential impact on guideline recommendations upon publication will be monitored.

Topic experts highlighted issues with the implementation of some recommendations from the 2016 update of the guideline on the use of CCTA in stable chest pain. The availability of suitable scanners and professionals were reported to pose difficulties with implementation of the recommendations. These issues were explored in this surveillance review (as detailed in implementation of the guideline). No evidence was identified indicating that any alternative diagnostic imaging test would have superior performance to CCTA in stable chest pain and so we considered there to be no potential impact on recommendations in this area. However, we will ensure that the information on implementation issues gathered in this surveillance review is disseminated through appropriate channels within NICE.

We also considered external correspondence received, which requested the inclusion of further guidance on diagnosis of aortic dissection in this guideline. In order to inform our consideration of this point, we consulted with the topic experts already engaged with this surveillance review and additional experts in emergency medicine. While the expert views we received on whether additional guidance should be included on diagnosis of aortic dissection were mixed, more experts overall considered that this would not be appropriate within this guideline. This issue is described in more detail in other sources of information.

We considered stakeholder consultation comments and added a further 7 studies from stakeholder feedback into the summary of evidence (see appendix A). This evidence was considered either to support existing recommendations or not provide direct evidence of whether any alternative diagnostic imaging test would have superior performance to CCTA in stable chest pain. Therefore, the evidence identified at surveillance was not considered to demonstrate potential impact on existing recommendations.

For further details and a summary of all evidence identified in surveillance, see appendix A.