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Early management of unstable angina and NSTEMI

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Chest pain

About

What is covered

This interactive flowchart covers:
  • assessing and diagnosing recent-onset chest pain of suspected cardiac origin in people with acute chest pain and a suspected acute coronary syndrome, and people with intermittent stable chest pain and suspected stable angina
  • the early management of unstable angina and myocardial infarction with non-ST-segment elevation
  • the early management of stable angina.

Updates

Updates to this interactive flowchart

13 February 2017 HeartFlow FFRCT for estimating fractional flow reserve from coronary CT angiography (NICE medical technologies guidance 32) added to diagnostic investigations for suspected stable angina.

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on assessing and managing recent suspected cardiac chest pain including acute coronary syndromes and stable angina in an interactive flowchart

What is covered

This interactive flowchart covers:
  • assessing and diagnosing recent-onset chest pain of suspected cardiac origin in people with acute chest pain and a suspected acute coronary syndrome, and people with intermittent stable chest pain and suspected stable angina
  • the early management of unstable angina and myocardial infarction with non-ST-segment elevation
  • the early management of stable angina.

Updates

Updates to this interactive flowchart

13 February 2017 HeartFlow FFRCT for estimating fractional flow reserve from coronary CT angiography (NICE medical technologies guidance 32) added to diagnostic investigations for suspected stable angina.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Stable angina: management (2011 updated 2016) NICE guideline CG126
Chest pain of recent onset: assessment and diagnosis (2010 updated 2016) NICE guideline CG95
Ticagrelor for the treatment of acute coronary syndromes (2011) NICE technology appraisal guidance 236
Drug-eluting stents for the treatment of coronary artery disease (2008) NICE technology appraisal guidance 152
Guidance on the use of coronary artery stents (2003) NICE technology appraisal guidance 71
Endoscopic saphenous vein harvest for coronary artery bypass grafting (2014) NICE interventional procedures guidance 494
Bioresorbable stent implantation for treating coronary artery disease (2014) NICE interventional procedures guidance 492
Optical coherence tomography to guide percutaneous coronary intervention (2014) NICE interventional procedures guidance 481
Percutaneous laser coronary angioplasty (2011) NICE interventional procedures guidance 378
Off-pump coronary artery bypass grafting (2011) NICE interventional procedures guidance 377
Percutaneous laser revascularisation for refractory angina pectoris (2009) NICE interventional procedures guidance 302
Transmyocardial laser revascularisation for refractory angina pectoris (2009) NICE interventional procedures guidance 301
Endoaortic balloon occlusion for cardiac surgery (2008) NICE interventional procedures guidance 261
Totally endoscopic robotically assisted coronary artery bypass grafting (2005) NICE interventional procedures guidance 128
Thrombin injections for pseudoaneurysms (2004) NICE interventional procedures guidance 60
CardioQ-ODM oesophageal doppler monitor (2011) NICE medical technologies guidance 3
SeQuent Please balloon catheter for in-stent coronary restenosis (2010) NICE medical technologies guidance 1
Acute coronary syndromes in adults (2014) NICE quality standard 68
Stable angina (2012) NICE quality standard 21
Coronary revascularisation: cangrelor (2015) NICE evidence summary ESNM63
Sternal Talon for sternal closure in cardiothoracic surgery (2016) NICE medtech innovation briefing 88

Quality standards

Stable angina

These quality statements are taken from the stable angina quality standard. The quality standard defines clinical best practice in stable angina care and should be read in full.

Quality statements

Diagnosis of acute myocardial infarction

This quality statement is taken from the acute coronary syndromes (including myocardial infarction) quality standard. The quality standard defines clinical best practice for acute coronary syndromes (including myocardial infarction) and should be read in full.

Quality statement

Adults with a suspected acute coronary syndrome are assessed for acute myocardial infarction using the criteria in the universal definition of myocardial infarction.

Rationale

Acute myocardial infarction can have a poor prognosis so prompt and accurate diagnosis is important to ensure that appropriate treatment and care is offered as soon as possible. Treatment for adults with suspected acute coronary syndrome is often started before a diagnosis is confirmed. Confirming the diagnosis using the criteria in the universal definition of myocardial infarction is important to ensure that any ongoing treatment is appropriate and any inappropriate treatment is stopped.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with a suspected acute coronary syndrome are assessed for the presence of acute myocardial infarction using the criteria in the universal definition of myocardial infarction.
Data source: Local data collection.
Process
Proportion of adults with a diagnosis of acute myocardial infarction who had their diagnosis made using the criteria in the universal definition of myocardial infarction.
Numerator – the number in the denominator who had their diagnosis made using the criteria in the universal definition of myocardial infarction.
Denominator – the number of adults with a diagnosis of acute myocardial infarction.
Data source: Local data collection.

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

Service providers (cardiac service providers) ensure that adults with a suspected acute coronary syndrome are assessed for the presence of acute myocardial infarction using the criteria in the universal definition of myocardial infarction.
Healthcare professionals ensure that they are aware of the universal definition of myocardial infarction and assess adults with a suspected acute coronary syndrome for the presence of acute myocardial infarction using the criteria in the universal definition.
Commissioners (clinical commissioning groups) ensure that they commission services with staff with expertise in using the criteria in the universal definition of myocardial infarction to diagnose acute myocardial infarction in adults with a suspected acute coronary syndrome.

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

Adults with severe pain in the chest and/or in other areas (for example, the arms, back or jaw) that might be a heart attack (a suspected acute coronary syndrome) are only given a diagnosis of heart attack if their signs and symptoms meet an agreed definition.

Source guidance

Definitions of terms used in this quality statement

Universal definition of myocardial infarction
A rise in cardiac biomarkers (preferably cardiac troponin) with at least 1 value above the 99th percentile of the upper reference limit and/or a fall in cardiac biomarkers, together with at least 1 of the following:
  • symptoms of ischaemia
  • new or presumed new significant ST-segment-T wave changes or new left bundle branch block
  • pathological Q wave changes in the ECG
  • imaging evidence of new loss of viable myocardium or new regional wall motion abnormality
  • identification of an intracoronary thrombus by angiography.
[NICE clinical guideline 95, recommendation 1.2.6.1]

Equality and diversity considerations

Symptoms of acute coronary syndromes should be assessed in the same way in men and women and among people from different ethnic groups.

Risk assessment for adults with NSTEMI or unstable angina

This quality statement is taken from the acute coronary syndromes (including myocardial infarction) quality standard. The quality standard defines clinical best practice for acute coronary syndromes (including myocardial infarction) and should be read in full.

Quality statement

Adults with non-ST-segment-elevation myocardial infarction (NSTEMI) or unstable angina are assessed for their risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality to guide clinical management.

Rationale

Assessing and categorising risk of future adverse cardiovascular events by formal risk assessment (for example, using the GRACE scoring system) in people who have been diagnosed with NSTEMI or unstable angina is important for determining early management strategies. It also allows the benefits of treatment to be balanced against the risks of treatment related adverse events. Failure to categorise future risk can lead to people being given inappropriate treatment.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with NSTEMI or unstable angina are assessed for their risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality to guide clinical management.
Data source: Local data collection.
Process
Proportion of presentations for NSTEMI or unstable angina that had an assessment of the risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality.
Numerator – the number in the denominator that had an assessment of the risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality.
Denominator – the number of presentations because of NSTEMI or unstable angina.
Data source: Local data collection. Contained within NICE clinical guideline 94 audit support, criterion 1.

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

Service providers (cardiac service providers) ensure that local pathways are in place for adults with NSTEMI or unstable angina to be assessed for their risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality. Providers should also raise awareness among healthcare professionals of the importance of risk assessment in guiding clinical management.
Healthcare professionals ensure that they assess the risk of future adverse cardiovascular events in adults with NSTEMI or unstable angina using an established risk scoring system that predicts 6-month mortality to guide clinical management.
Commissioners (clinical commissioning groups) ensure that they commission services with staff with the expertise to assess the risk of future adverse cardiovascular events in adults with NSTEMI or unstable angina using established risk scoring systems that predict 6-month mortality to guide clinical management.

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

Adults with heart conditions called NSTEMI and unstable angina have their risk of another heart attack estimated to guide their treatment.

Source guidance

Definitions of terms used in this quality statement

Assessment for risk of future adverse cardiovascular events
Individual risk of future adverse cardiovascular events should be formally assessed using an established risk scoring system that predicts 6-month mortality (for example, Global Registry of Acute Cardiac Events [GRACE]).
The formal risk assessment should include:
  • a full clinical history (including age, previous myocardial infarction and previous percutaneous coronary intervention or coronary artery bypass grafting)
  • a physical examination (including measurement of blood pressure and heart rate)
  • resting 12-lead ECG (looking particularly for dynamic or unstable patterns that indicate myocardial ischaemia)
  • blood tests (such as troponin I or T, creatinine, glucose and haemoglobin).
[NICE clinical guideline 94, recommendations 1.2.1 and 1.2.2]
Categories for risk of future adverse cardiovascular events
Using 6-month mortality, the categories for the risk of future adverse cardiovascular events are:
Predicted 6-month mortality
Risk of future adverse cardiovascular events
1.5% or below
Lowest
>1.5 to 3.0%
Low
>3.0 to 6.0%
Intermediate
>6.0 to 9.0%
High
Over 9.0%
Highest
[NICE clinical guideline 94, recommendation 1.2.5]

Coronary angiography and PCI within 72 hours for NSTEMI or unstable angina

This quality statement is taken from the acute coronary syndromes (including myocardial infarction) quality standard. The quality standard defines clinical best practice for acute coronary syndromes (including myocardial infarction) and should be read in full.

Quality statement

Adults with non-ST-segment-elevation myocardial infarction (NSTEMI) or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events are offered coronary angiography (with follow-on percutaneous coronary intervention [PCI] if indicated) within 72 hours of first admission to hospital.

Rationale

Coronary angiography is important to define the extent and severity of coronary disease. In people with an intermediate or higher risk of future adverse cardiovascular events, coronary angiography within 72 hours of admission to hospital offers advantages over an initial conservative strategy, provided there are no contraindications to angiography (such as active bleeding or comorbidity). Services should provide coronary angiography (with follow-on PCI if indicated) as soon as it offers net clinical benefits; they should not wait until 72 hours if this is sooner.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events are offered coronary angiography (with follow-on PCI if indicated) within 72 hours of first admission to hospital.
Data source: Local data collection.
Process
Length of time taken for adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events 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.
Proportion of adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events who receive coronary angiography (with follow-on PCI if indicated) within 72 hours of first admission to hospital.
Numerator – the number of people in the denominator receiving coronary angiography (with follow-on PCI if indicated) within 72 hours of admission.
Denominator – the number of adults with NSTEMI or unstable angina with an intermediate or higher risk of future adverse cardiovascular events on admission to hospital.
Data source: Local data collection. Contained within NICE clinical guideline 94 audit support, criterion 9.
Outcome
Incidence of cardiovascular events.
Data source: Local data collection.

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

Service providers (cardiac service providers) ensure that local pathways are in place for adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events to be seen by cardiac specialists and offered coronary angiography (with follow-on PCI if indicated) within 72 hours of first admission to hospital.
Healthcare professionals ensure that they offer adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events, coronary angiography (with follow-on PCI if indicated) within 72 hours of first admission to hospital.
Commissioners (clinical commissioning groups) ensure that they commission services with the capacity and expertise to offer adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events, coronary angiography (with follow-on PCI if indicated) within 72 hours of first admission to hospital.

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

Adults with heart conditions called NSTEMI and unstable angina who have a medium or higher risk of another heart attack are offered a test called coronary angiography, and treatment to improve blood flow to the heart if needed, within 72 hours of first being admitted to hospital.

Source guidance

  • Unstable angina and NSTEMI (NICE clinical guideline 94) recommendation 1.5.1 [the timeframe of 72 hours, rather than 96 hours as stated in the recommendation, is based on consensus of expert opinion].

Definitions of terms used in this quality statement

Intermediate or higher risk of future adverse cardiovascular events
A predicted 6-month mortality above 3.0%. [NICE clinical guideline 94, recommendation 1.5.1]

Coronary angiography and PCI for adults with NSTEMI or unstable angina who are clinically unstable

This quality statement is taken from the acute coronary syndromes (including myocardial infarction) quality standard. The quality standard defines clinical best practice for acute coronary syndromes (including myocardial infarction) and should be read in full.

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
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.
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]

Level of consciousness and eligibility for coronary angiography and primary PCI

This quality statement is taken from the acute coronary syndromes (including myocardial infarction) quality standard. The quality standard defines clinical best practice for acute coronary syndromes (including myocardial infarction) and should be read in full.

Quality statement

Adults who are unconscious after cardiac arrest caused by suspected acute ST segment elevation myocardial infarction (STEMI) are not excluded from having coronary angiography (with follow–on primary percutaneous coronary intervention [PCI] if indicated).

Rationale

People who remain unconscious after cardiac arrest should not be treated differently from people who are conscious. They should be able to have the same treatments within the same timescales and should be admitted to centres capable of undertaking primary PCI. Carrying out immediate primary PCI, if successful, could stabilise the person’s heart and may reduce the risk of further complications.

Quality measures

Structure
Evidence of local arrangements to ensure that adults who are unconscious after cardiac arrest caused by suspected acute STEMI are not excluded from having coronary angiography (with follow–on primary PCI if indicated) because they are unconscious.
Data source: Local data collection.
Process
Proportion of adults who were unconscious after cardiac arrest caused by suspected acute STEMI who receive coronary angiography (with follow-on primary PCI if indicated).
Numerator – the number in the denominator receiving coronary angiography (with follow-on primary PCI if indicated).
Denominator – the number of adults who were unconscious after cardiac arrest caused by suspected acute STEMI.
Data source: Local data collection.

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

Service providers (ambulance services and cardiac service providers) ensure that adults who are unconscious after cardiac arrest caused by suspected acute STEMI are not excluded from having coronary angiography (with follow–on primary PCI if indicated). Providers should also raise awareness among healthcare professionals of the importance of not using level of consciousness to exclude adults from having coronary angiography (with follow–on primary PCI if indicated).
Healthcare professionals ensure that they do not use level of consciousness after cardiac arrest caused by suspected acute STEMI to exclude adults from having coronary angiography (with follow–on primary PCI if indicated).
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services that can carry out coronary angiography (with follow–on primary PCI if indicated) in adults who are unconscious after cardiac arrest caused by suspected acute STEMI.

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

Adults who are unconscious after a type of heart attack called STEMI can have a test called coronary angiography, and treatment to improve blood flow to the heart if needed, even though they are unconscious.

Source guidance

Primary PCI for acute STEMI

This quality statement is taken from the acute coronary syndromes (including myocardial infarction) quality standard. The quality standard defines clinical best practice for acute coronary syndromes (including myocardial infarction) and should be read in full.

Quality statement

Adults with acute ST-segment-elevation myocardial infarction (STEMI) who present within 12 hours of onset of symptoms have primary percutaneous coronary intervention (PCI), as the preferred coronary reperfusion strategy, as soon as possible but within 120 minutes of the time when fibrinolysis could have been given.

Rationale

Primary PCI is a form of reperfusion therapy which should be done as soon as possible. This is because heart muscle starts to be lost once a coronary artery is blocked and the sooner reperfusion therapy is delivered the better the outcome for the patient. If too much time elapses the benefits of primary PCI may be lost. Because of the difficulty in timely delivery, in some areas primary PCI is no longer the preferred coronary reperfusion strategy over fibrinolysis. However, when performed early, primary PCI is more effective. To ensure the best outcomes for adults with STEMI, the ambulance service and hospitals delivering primary PCI should work together to minimise delays in treatment.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with acute STEMI who present within 12 hours of onset of symptoms have primary PCI, as the preferred coronary reperfusion strategy, within 120 minutes of the time when fibrinolysis could have been given.
Data source: Local data collection.
Evidence of local arrangements to ensure that adults with acute STEMI have access to primary PCI 24 hours a day.
Data source: Local data collection.
Evidence that commissioners with their services providers have developed a single care pathway for coronary reperfusion.
Data source: Local data collection.
Process
Proportion of adults with acute STEMI who present within 12 hours of onset of symptoms who receive primary PCI within 120 minutes of when fibrinolysis could have been given.
Numerator – the number in the denominator receiving primary PCI within 120 minutes of when fibrinolysis could have been given.
Denominator – the number of adults with acute STEMI who present within 12 hours of onset of symptoms.
Data source: Local data collection. Some fields on time to primary PCI collected in Myocardial Ischaemia National Audit Project (MINAP) and National audit of percutaneous coronary interventional procedures (BCIS).
Proportion of adults with acute STEMI who present within 12 hours of onset of symptoms who receive primary PCI within 150 minutes of the call for professional help.
Numerator – the number of people in the denominator receiving primary PCI within 150 minutes of the call for professional help.
Denominator – the number of adults with acute STEMI who present within 12 hours of onset of symptoms.
Outcome
Incidence of cardiovascular events.
Data source: Local data collection.

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

Service providers (ambulance services, accident and emergency service provider and cardiac service providers) ensure that local pathways and transfer protocols are in place for adults with acute STEMI who present within 12 hours of the onset of symptoms to be offered primary PCI, as the preferred coronary reperfusion strategy, as soon as possible but within 120 minutes of when fibrinolysis could have been given.
Healthcare professionals ensure that they offer primary PCI, as the preferred coronary reperfusion strategy, as soon as possible but within 120 minutes of when fibrinolysis could have been given to adults with acute STEMI who present within 12 hours of the onset of symptoms.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services that have the capacity and expertise to provide primary PCI, as the preferred coronary reperfusion strategy, as soon as possible but within 120 minutes of when fibrinolysis could have been given (and at any time of the day or night, including weekends) to adults with acute STEMI who present within 12 hours of onset of symptoms. Commissioners should work with their service providers to develop a single care pathway for coronary reperfusion.

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

Adults with a type of heart attack called STEMI whose symptoms started no more than 12 hours before first contacting a healthcare professional are offered a procedure to improve blood flow to the heart (called percutaneous coronary intervention or PCI). They should be able to have this as soon as possible, but within 120 minutes of when they could have received fibrinolysis (a ‘clot-busting’ drug).

Source guidance

Diagnostic investigation

This quality statement is taken from the stable angina quality standard. The quality standard defines clinical best practice for stable angina and should be read in full.

Quality statement

People with features of typical or atypical angina are offered 64-slice (or above) CT coronary angiography.

Quality measure

Structure
Evidence of local arrangements to ensure that people with features of typical or atypical angina are offered 64-slice (or above) CT coronary angiography.
Process
Proportion of people with features of typical or atypical angina who receive 64-slice (or above) CT coronary angiography.
Numerator – the number of people in the denominator who receive 64-slice (or above) CT coronary angiography.
Denominator – the number of people with features of typical or atypical angina.

What the quality statement means for each audience

Service providers ensure systems are in place so that people with features of typical or atypical angina are offered 64-slice (or above) CT coronary angiography.
Healthcare professionals offer 64-slice (or above) CT coronary angiography to people with features of typical or atypical angina.
Commissioners ensure they commission services that offer 64-slice (or above) CT coronary angiography to people with features of typical or atypical angina.
People who have been assessed and may have angina are offered CT coronary angiography (a procedure to check for narrowed or blocked arteries) to confirm any diagnosis.

Source guidance

NICE clinical guideline 95 recommendation 1.3.4.3

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

NICE clinical guideline 95 recommendation 1.3.3.1 describes the features of angina.

First-line treatment

This quality statement is taken from the stable angina quality standard. The quality standard defines clinical best practice for stable angina and should be read in full.

Quality statement

People with stable angina are offered a short-acting nitrate and either a beta-blocker or calcium-channel blocker as first-line treatment.

Quality measure

Structure
Evidence of local arrangements to ensure that people with stable angina are offered a short-acting nitrate and either a beta-blocker or calcium-channel blocker as first-line treatment.
Process
Proportion of people newly diagnosed with stable angina who are prescribed a short-acting nitrate and either a beta-blocker or calcium-channel blocker as first-line treatment.
Numerator – the number of people in the denominator prescribed a short-acting nitrate and either a beta-blocker or calcium-channel blocker as first-line treatment.
Denominator – the number of people newly diagnosed with stable angina.

What the quality statement means for each audience

Service providers ensure systems are in place to offer people with stable angina a short-acting nitrate and either a beta-blocker or a calcium-channel blocker as first-line treatment.
Healthcare professionals offer people with stable angina a short-acting nitrate and either a beta-blocker or a calcium-channel blocker as first-line treatment.
Commissioners ensure they commission services that offer people with stable angina a short-acting nitrate and either a beta-blocker or a calcium-channel blocker as first-line treatment.
People with stable angina are offered drug treatment to take for immediate relief from an attack of angina (a short-acting nitrate) and another drug to take every day (either a beta-blocker or a calcium-channel blocker) to prevent episodes of stable angina.

Source guidance

NICE clinical guideline 126 recommendations 1.3.3 and 1.4.7.

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE audit support for management of stable angina (NICE clinical guideline 126): criteria 1 and 5a.

Medical treatment before revascularisation

This quality statement is taken from the stable angina quality standard. The quality standard defines clinical best practice for stable angina and should be read in full.

Quality statement

People with stable angina are prescribed a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary, before revascularisation is considered.

Quality measure

Structure
Evidence of local arrangements to ensure that people with stable angina are prescribed a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary before revascularisation is considered.
Process
Proportion of people with stable angina who are prescribed a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary before revascularisation is considered.
Numerator – the number of people in the denominator prescribed a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary before revascularisation is considered.
Denominator – the number of people with stable angina considered for revascularisation.

What the quality statement means for each audience

Service providers ensure systems are in place to prescribe a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary for people with stable angina before revascularisation is considered.
Healthcare professionals prescribe a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary before revascularisation is considered in people with stable angina.
Commissioners ensure they commission services that prescribe a short-acting nitrate and 1 or 2 anti-anginal drugs as necessary for people with stable angina before considering revascularisation.
People with stable angina are prescribed a short-acting nitrate and 1 or 2 drugs as necessary to prevent angina before revascularisation (an operation to improve blood flow) is considered.

Source guidance

NICE clinical guideline 126 recommendations 1.3.3, 1.4.8, 1.4.9, 1.4.11, 1.4.12 and 1.5.1.

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE audit support for management of stable angina (NICE clinical guideline 126): criteria 1, 5c, 7a and 7b.

Definitions

Prescribing 1 or 2 anti-anginal drugs as necessary
NICE clinical guideline 126 section 1.4 contains recommendations on the correct treatment when anti-anginal drugs are contraindicated, not tolerated or when symptoms are not satisfactorily controlled.
NICE clinical guideline 126 recommendation 1.4.8: If the person cannot tolerate the beta-blocker or calcium-channel blocker, consider switching to the other option (calcium-channel blocker or beta-blocker).
NICE clinical guideline 126 recommendation 1.4.9: If the person's symptoms are not satisfactorily controlled on a beta-blocker or a calcium-channel blocker, consider either switching to the other option or using a combination of the 2.When combining a calcium-channel blocker with a beta-blocker, use a dihydropyridine calcium-channel blocker, for example, slow release nifedipine, amlodipine or felodipine.
NICE clinical guideline 126 recommendation 1.4.11: If the person cannot tolerate beta-blockers and calcium-channel blockers or both are contraindicated, consider monotherapy with 1 of the following drugs:
  • a long-acting nitrate or
  • ivabradine or
  • nicorandil or
  • ranolazine.
Decide which drug to use based on comorbidities, contraindications, the person's preference and drug costs.Since the NICE guideline was produced, the Medicines and Healthcare products Regulatory Agency (MHRA) have published new advice about safety concerns related to ivabradine (June 2014 and December 2014) and nicorandil (January 2016).
NICE clinical guideline 126 recommendation 1.4.12: For people on beta-blocker or calcium-channel blocker monotherapy whose symptoms are not controlled and the other option (calcium-channel blocker or beta-blocker) is contraindicated or not tolerated, consider 1 of the following as an additional drug:
  • a long-acting nitrate or
  • ivabradineWhen combining ivabradine with a calcium-channel blocker, use a dihydropyridine calcium-channel blocker, for example, slow release nifedipine, amlodipine, or felodipine. or
  • nicorandil or
  • ranolazine.
Decide which drug to use based on comorbidities, contraindications, the person's preference and drug costs.

Multidisciplinary team

This quality statement is taken from the stable angina quality standard. The quality standard defines clinical best practice for stable angina and should be read in full.

Quality statement

People with stable angina who have had coronary angiography, have their treatment options discussed by a multidisciplinary team if there is left main stem disease, anatomically complex three-vessel disease or doubt about the best method of revascularisation.

Quality measure

Structure
Evidence of local arrangements to provide a multidisciplinary team to discuss the risks and benefits of continuing drug treatment or revascularisation strategy for people with stable angina.
Process
Proportion of people with stable angina who have had coronary angiography who have their treatment options discussed by a multidisciplinary team if there is left main stem disease, anatomically complex three-vessel disease or doubt about the best method of revascularisation.
Numerator – the number of people in the denominator who have their treatment options discussed by a multidisciplinary team.
Denominator – the number of people with stable angina who have had coronary angiography who have left main stem disease or anatomically complex three-vessel disease, or if there is doubt about the best method of revascularisation.

What the quality statement means for each audience

Service providers ensure a multidisciplinary team discusses the treatment options for people with stable angina who have had coronary angiography, if there is left main stem disease, anatomically complex three-vessel disease or doubt about the best method of revascularisation.
Healthcare professionals ensure people with stable angina who have had coronary angiography have their treatment options discussed by a multidisciplinary team if there is left main stem disease, anatomically complex three-vessel disease or doubt about the best method of revascularisation.
Commissioners ensure they commission services that provide a multidisciplinary team to discuss the treatment options for people with stable angina who have had coronary angiography, if there is left main stem disease, anatomically complex three-vessel disease or doubt about the best method of revascularisation.
People with stable angina who have had coronary angiography (a procedure to check for narrowed or blocked arteries) have their treatment options discussed by a multi-disciplinary team, including a heart surgeon and specialist in heart procedures, if needed.

Source guidance

NICE clinical guideline 126 recommendation 1.5.8.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

NICE clinical guideline 126 does not describe the composition of the multidisciplinary team but does state that it should include cardiac surgeons and interventional cardiologists.
The criteria for discussion of treatment options by a multidisciplinary team are not limited to left main stem or anatomically complex three-vessel disease or doubt about the best method of revascularisation. These are specific examples used to aid measurability.

Symptoms not responding to treatment

This quality statement is taken from the stable angina quality standard. The quality standard defines clinical best practice for stable angina and should be read in full.

Quality statement

People with stable angina whose symptoms have not responded to treatment are offered a re-evaluation of their diagnosis and treatment.

Quality measure

Structure
Evidence of local arrangements to ensure that people with stable angina whose symptoms have not responded to treatment are offered a re-evaluation of their diagnosis and treatment.
Process
Proportion of people with stable angina whose symptoms have not responded to treatment who have their diagnosis and treatment re-evaluated.
Numerator – the number of people in the denominator who have their diagnosis and treatment re-evaluated.
Denominator – the number of people with stable angina whose symptoms have not responded to treatment.

What the quality statement means for each audience

Service providers ensure systems are in place to re-evaluate the diagnosis and treatment of people with stable angina whose symptoms have not responded to treatment.
Healthcare professionals offer re-evaluation of diagnosis and treatment to people with stable angina whose symptoms have not responded to treatment.
Commissioners ensure they commission services that re-evaluate the diagnosis and treatment of people with stable angina whose symptoms have not responded to treatment.
People with stable angina whose symptoms are not improving with treatment are offered a re-evaluation of their diagnosis and treatment.

Source guidance

NICE clinical guideline 126 recommendation 1.7.1.

Data source

Structure
Local data collection.
Process
Local data collection.

Definitions

NICE clinical guideline 126 recommendation 1.7.1 describes the components that may be included in a re-evaluation of diagnosis and treatment:
  • exploring the person's understanding of their condition
  • exploring the impact of symptoms on the person's quality of life
  • reviewing the diagnosis and considering non-ischaemic causes of pain
  • reviewing drug treatment and considering future drug treatment and revascularisation options
  • acknowledging the limitations of future treatment
  • explaining how the person can manage the pain themselves
  • specific attention to the role of psychological factors in pain
  • development of skills to modify cognitions and behaviours associated with pain.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

If an acute coronary syndrome has been excluded at any point in the care pathway, but people have risk factors for cardiovascular disease, follow the appropriate guidance, for example in NICE's recommendations on cardiovascular disease prevention or hypertension.
Monitor people with acute chest pain, using clinical judgement to decide how often this should be done, until a firm diagnosis is made. This should include:
  • exacerbations of pain and/or other symptoms
  • pulse and blood pressure
  • heart rhythm
  • oxygen saturation by pulse oximetry
  • repeated resting 12-lead ECGs and
  • checking pain relief is effective.

Significant coronary artery disease

Significant coronary artery disease found during CT coronary angiography is ≥ 70% diameter stenosis of at least one major epicardial artery segment or ≥50% diameter stenosis in the left main coronary artery.
Factors intensifying ischaemia
Such factors allow less severe lesions (for example ≥50%) to produce angina:
  • reduced oxygen delivery: anaemia, coronary spasm
  • increased oxygen demand: tachycardia, left ventricular hypertrophy
  • large mass of ischaemic myocardium: proximally located lesions
  • longer lesion length.
Factors reducing ischaemia which may render severe lesions (≥70%) asymptomatic:
  • well-developed collateral supply
  • small mass of ischaemic myocardium: distally located lesions, old infarction in the territory of coronary supply.

VeriQ system for assessing graft flow during coronary artery bypass graft surgery

The following recommendations are from NICE medical technologies guidance on the VeriQ system for assessing graft flow during coronary artery bypass graft surgery.
The case for adopting the VeriQ system in the NHS for assessing graft flow during CABG surgery is supported by the evidence. The evidence suggests that intra-operative transit time flow measurement is effective in detecting imperfections that may be corrected by graft revision. This may reduce the incidence of graft occlusion and may reduce perioperative morbidity and mortality.
The VeriQ system is associated with an estimated cost saving of £115 per patient compared with clinical assessment, when it is used routinely for assessing coronary artery bypass grafts during surgery.

Detecting, managing and monitoring haemostasis: viscoelastometric point-of-care testing

The ROTEM system and the TEG system are recommended to help detect, manage and monitor haemostasis during and after cardiac surgery.
The Sonoclot system is only recommended for use in research to help detect, manage and monitor haemostasis during and after cardiac surgery. Research is recommended into the clinical benefits and cost effectiveness of using the Sonoclot system during and after cardiac surgery (see section 7.1 of the guidance).
Healthcare professionals using the ROTEM system and the TEG system during cardiac surgery should have appropriate training and experience with these devices.

'Depth of anaesthesia' monitors

The following recommendations are from NICE diagnostics guidance on depth of anaesthesia monitors.
The use of EEG-based depth of anaesthesia monitors is recommended as an option during any type of general anaesthesia in patients considered at higher risk of adverse outcomes. This includes patients at higher risk of unintended awareness and patients at higher risk of excessively deep anaesthesia. The BIS depth of anaesthesia monitor is therefore recommended as an option in these patients.
The use of EEG-based depth of anaesthesia monitors is also recommended as an option in all patients receiving total intravenous anaesthesia. The BIS monitor is therefore recommended as an option in these patients.
Although there is greater uncertainty of clinical benefit for the E-Entropy and Narcotrend-Compact M depth of anaesthesia monitors than for the BIS monitor, the Committee concluded that the E-Entropy and Narcotrend-Compact M monitors are broadly equivalent to BIS. These monitors are therefore recommended as options during any type of general anaesthesia in patients considered at higher risk of adverse outcomes. This includes patients at higher risk of unintended awareness and patients at higher risk of excessively deep anaesthesia. The E-Entropy and Narcotrend-Compact M monitors are also recommended as options in patients receiving total intravenous anaesthesia.
Anaesthetists using EEG-based depth of anaesthesia monitors should have appropriate training and experience with these monitors and understand the potential limitations of their use in clinical practice.

CardioQ-ODM oesophageal doppler monitor

The following recommendations are from NICE medical technologies guidance on CardioQ-ODM oesophageal doppler monitor.
The case for adopting the CardioQ-ODM in the NHS, when used as described below, is supported by the evidence. There is a reduction in post-operative complications, use of central venous catheters and in-hospital stay (with no increase in the rate of re-admission or repeat surgery) compared with conventional clinical assessment with or without invasive cardiovascular monitoring. The cost saving per patient, when the CardioQ-ODM is used instead of a central venous catheter in the peri-operative period, is about £1100 based on a 7.5-day hospital stay.
The CardioQ-ODM should be considered for use in patients undergoing major or high-risk surgery or other surgical patients in whom a clinician would consider using invasive cardiovascular monitoring.

Interventional procedures

NICE has published guidance on the following procedures with normal arrangements for clinical governance, consent and audit:
NICE has published guidance on totally endoscopic robotically assisted coronary artery bypass grafting with special arrangements for consent and audit or research.
NICE has published guidance on intraoperative fluorescence angiography in coronary artery bypass grafting (see guidance for details).
The following recommendations are from NICE technology appraisal guidance on the use of coronary artery stents.
Stents should be used routinely where PCI is the clinically appropriate procedure for patients with either stable or unstable angina or with acute myocardial infarction.
This guidance specifically relates to the present clinical indications for PCI and excludes conditions (such as many cases of stable angina) that are adequately managed with standard drug therapy.
NICE has written information for the public explaining its guidance on coronary artery stents.

Drug-eluting stents

The following recommendation is from NICE technology appraisal guidance on drug-eluting stents for the treatment of coronary artery disease.
Drug-eluting stents are recommended for use in PCI for the treatment of coronary artery disease, within their instructions for use, only if:
  • the target artery to be treated has less than a 3-mm calibre or the lesion is longer than 15 mm, and
  • the price difference between drug-eluting stents and bare-metal stents is no more than £300.
NICE has written information for the public explaining its guidance on drug-eluting stents.

Bioresorbable stents

NICE has published interventional procedures guidance on bioresorbable stent implantation for treating coronary artery disease with special arrangements for clinical governance, consent and audit or research.
NICE has published a medtech innovation briefing on Absorb Bioresorbable Vascular Scaffold for coronary artery disease.

Interventional procedures

NICE has published guidance on:

Medtech innovation briefings

NICE has published medtech innovation briefings on:

People who have previously had PCI

SeQuent Please balloon catheter for in-stent coronary restenosis

The following recommendations are from NICE medical technologies guidance on SeQuent Please balloon catheter for in-stent coronary restenosis.
The case for adopting SeQuent Please balloon catheter in the NHS, when used as described below, is supported by the evidence. The need for subsequent re-intervention for coronary stenosis is reduced as is the duration of clopidogrel therapy, compared with paclitaxel-eluting stent. SeQuent Please balloon catheter is associated with a cost saving of £467 per patient compared with paclitaxel-eluting stent.
SeQuent Please balloon catheter should be considered for use in patients with in-stent restenosis in bare metal coronary artery stents.
SeQuent Please balloon catheter can also be considered as an option for patients with in-stent restenosis in any type of coronary artery stent if:
  • there are clinical reasons to minimise the duration of clopidogrel treatment (for example, there is concern about an increased risk of bleeding or there is the need for surgical intervention) or
  • placement of further stents is not technically possible.
Further research is recommended in a UK setting to compare the outcomes of patients treated with SeQuent Please balloon catheter with the outcomes of patients treated with other types of drug-eluting balloon catheter and stent. This research should report long-term outcomes (for example, after 3 years), including clinical outcomes and details of further revascularisation required for subsequent restenosis. Research should investigate the use of SeQuent Please balloon catheter for restenosis in drug-eluting coronary artery stents and in de novo coronary stenosis where stenting is either technically difficult or is associated with an increased risk of complications. If research shows that SeQuent Please balloon catheter reduces the rate of restenosis in patients with drug-eluting stents or in native coronary arteries, compared with other technologies, then the number of patients for whom it might be suitable would increase significantly.

Glossary

angiotensin-converting enzyme
Bispectral Index
coronary artery bypass graft
electrocardiogram
electroencephalography
Global Registry of Acute Coronary Events
glyceryl trinitrate
myocardial perfusion scintigraphy with single photon emission CT
non-ST-segment elevation myocardial infarction
percutaneous coronary intervention
single photon emission CT
ST-segment elevation myocardial infarction
ST-segment-T-wave

Paths in this pathway

Pathway created: November 2016 Last updated: May 2017

© NICE 2017

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