Fresh guidance has been issued to GPs to help in the early diagnosis of the cause of chest pain, to prevent unnecessary deaths from heart attacks.
The guidance suggests that some tests, such as monitoring the heart while the patient is exercising on a treadmill, could be replaced with scans.
An electrical test (12-lead ECG) should be carried out as soon as possible on people complaining of acute chest pain and who are likely to be suffering some kind of heart attack or angina, NICE has said.
But patients should not be delayed in getting to hospital just because the results of any tests are not ready. Medics are now being advised not to administer oxygen routinely because it may actually make a person’s condition worse; instead they should monitor the amount of oxygen in the patient’s blood.
Clinical assessment should be able to diagnose the cause of intermittent, stable chest pain, but if necessary, testing should be used, the guidance states.
Other possible causes, such as indigestion or muscular pain, should be ruled out first, although a patient’s medical history and heart risk factors must also be considered.
Recommendations in the guideline for people with acute chest pain and suspected ACS include:
- Take a resting 12-lead ECG as soon as possible. When people are referred, send the results to hospital before they arrive if possible. Recording and sending the ECG should not delay transfer to hospital.
- Do not exclude an ACS when people have normal resting 12-lead ECG.
- Do not routinely administer oxygen, but monitor oxygen saturation using pulse oximetry as soon as possible, ideally before hospital admission, to guide the use of supplemental oxygen.
- Do not assess symptoms of an ACS differently in different ethnic groups.
Recommendations for people with intermittent stable chest pain who may have stable angina include:
- Diagnose stable angina based on either clinical assessment alone or where there is uncertainty, clinical assessment plus diagnostic testing (that is, anatomical testing for obstructive coronary artery disease [CAD] and/or functional testing for myocardial ischaemia (where the blood supply to the heart is restricted).
- If people have features of typical angina based on clinical assessment and their estimated likelihood of CAD is greater than 90%, further diagnostic investigation is unnecessary and should be managed as angina.
- Unless clinical suspicion is raised based on other aspects of the history and risk factors, exclude a diagnosis of stable angina if the pain is non-anginal and first consider causes of pain other than angina (such as gastrointestinal or musculoskeletal pain).
- In people without confirmed CAD, in whom a diagnosis of stable angina cannot be made or excluded based on clinical assessment alone, estimate the likelihood of CAD, taking into account the clinical assessment and the resting 12-lead ECG. Arrange further diagnostic testing according to the estimated likelihood of CAD.
- Do not use exercise ECG to diagnose or exclude stable angina for people without known CAD.