Differences between National Institute for Health and Care Excellence and European Society of Cardiology guidelines in the diagnosis of chest pain and stable coronary artery disease

    Authors

    Keywords

    coronary artery disease, chest pain, guidelines

    DOI

    https://doi.org/10.15836/ccar2018.385

    Full Text

    Introduction: Chest pain is the most frequent symptom of coronary artery disease (CAD). Previous systematic review including 31 countries found average weighted prevalence of angina in males to be 5.7% and 6.7% in women. ( 1 ) In primary care the prevalence of patients presenting with chest pain that ultimately have CAD, is even lower, estimated to be around 1-2%. ( 2 ) Not every chest pain is associated with CAD, and physicians are using various methods to predict and diagnose CAD in patients with chest pain. Cardiology practice in the UK is guided by the use of National Institute for Health and Care Excellence (NICE) and European Society of Cardiology (ESC) Guidelines. Cardiologists in Europe guide their decisions according to ESC guidelines. This review is comparing scientific background for differences between most recent NICE and ESC guidelines in the diagnostic of chest pain and stable CAD that guide physician’s decision making in daily clinical practice. Comparison of Guidelines: In 2010 NICE published guidelines for diagnosis, and in 2011 for management of stable CAD. In November 2016, NICE published update of those guidelines. ( 3 ) This update consist of two important changes considering the use of pre-test probability assessment, and introduction of wide use of cardiac CT in the diagnosis of CAD. The last ESC guidelines for diagnosis and management of stable CAD were published in 2013. ESC Guidelines combined both CAD diagnostic and management guidelines. Statements are given according to the class of recommendation and level of evidence. This form of guidance is not applied in NICE, where rather simple statements are used. ESC guidelines do not assess cost-effectiveness of the recommendation, as opposed to the NICE Guidelines. Conclusion: Differences exist between NICE and ESC guidelines affecting clinical practice in approaching diagnostic of chest pain and stable CAD. The ESC pathway for diagnosis of chest pain is based on the functional/stress imaging, that can be replaced with exercise ECG if stress imaging facilities are not locally available. On the other hand, NICE guidelines moved away from exercise ECG, first towards more accurate functional stress imaging modalities, and later, according to the last update from 2016, towards 64-slice CT coronary angiography as a first line imaging modality.

    Cardiologia Croatica
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    Differences between National Institute for Health and Care Excellence and European Society of Cardiology guidelines in the diagnosis of chest pain and stable coronary artery disease

    Extended Abstract
    Issue11-12
    Published
    Pages385
    PDF via DOIhttps://doi.org/10.15836/ccar2018.385
    coronary artery disease
    chest pain
    guidelines

    Authors

    Diana Rudan*University Hospital Dubrava, Zagreb, Croatia
    Hrvojka Marija ZeljkoUniversity Hospital Dubrava, Zagreb, Croatia

    Full Text

    Introduction: Chest pain is the most frequent symptom of coronary artery disease (CAD). Previous systematic review including 31 countries found average weighted prevalence of angina in males to be 5.7% and 6.7% in women. ( 1 ) In primary care the prevalence of patients presenting with chest pain that ultimately have CAD, is even lower, estimated to be around 1-2%. ( 2 ) Not every chest pain is associated with CAD, and physicians are using various methods to predict and diagnose CAD in patients with chest pain. Cardiology practice in the UK is guided by the use of National Institute for Health and Care Excellence (NICE) and European Society of Cardiology (ESC) Guidelines. Cardiologists in Europe guide their decisions according to ESC guidelines. This review is comparing scientific background for differences between most recent NICE and ESC guidelines in the diagnostic of chest pain and stable CAD that guide physician’s decision making in daily clinical practice. Comparison of Guidelines: In 2010 NICE published guidelines for diagnosis, and in 2011 for management of stable CAD. In November 2016, NICE published update of those guidelines. ( 3 ) This update consist of two important changes considering the use of pre-test probability assessment, and introduction of wide use of cardiac CT in the diagnosis of CAD. The last ESC guidelines for diagnosis and management of stable CAD were published in 2013. ESC Guidelines combined both CAD diagnostic and management guidelines. Statements are given according to the class of recommendation and level of evidence. This form of guidance is not applied in NICE, where rather simple statements are used. ESC guidelines do not assess cost-effectiveness of the recommendation, as opposed to the NICE Guidelines. Conclusion: Differences exist between NICE and ESC guidelines affecting clinical practice in approaching diagnostic of chest pain and stable CAD. The ESC pathway for diagnosis of chest pain is based on the functional/stress imaging, that can be replaced with exercise ECG if stress imaging facilities are not locally available. On the other hand, NICE guidelines moved away from exercise ECG, first towards more accurate functional stress imaging modalities, and later, according to the last update from 2016, towards 64-slice CT coronary angiography as a first line imaging modality.