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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

27 February 2019 Air pollution: outdoor air quality and health (NICE quality standard 181) added.
27 November 2018 Percutaneous insertion of a temporary heart pump for left ventricular haemodynamic support in high-risk percutaneous coronary interventions (NICE interventional procedures guidance 633) added to managing stable angina and early management of unstable angina and NSTEMI.
19 February 2018 Recommendations updated in managing stable angina and early management of unstable angina and NSTEMI related to the cost savings of NICE medical technologies guidance on MiraQ for assessing graft flow during coronary artery bypass graft surgery.
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.

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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services 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 guideline should be interpreted in a way that would be inconsistent with complying 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.

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

27 February 2019 Air pollution: outdoor air quality and health (NICE quality standard 181) added.
27 November 2018 Percutaneous insertion of a temporary heart pump for left ventricular haemodynamic support in high-risk percutaneous coronary interventions (NICE interventional procedures guidance 633) added to managing stable angina and early management of unstable angina and NSTEMI.
19 February 2018 Recommendations updated in managing stable angina and early management of unstable angina and NSTEMI related to the cost savings of NICE medical technologies guidance on MiraQ for assessing graft flow during coronary artery bypass graft surgery.
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
MiraQ for assessing graft flow during coronary artery bypass graft surgery (2011 updated 2018) NICE medical technologies guidance 8
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
Air pollution: outdoor air quality and health (2019) NICE quality standard 181
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
VEST external stent for coronary artery bypass grafts (2017) NICE medtech innovation briefing 115
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.

Air pollution: outdoor air quality and health

These quality statements are taken from the air pollution: outdoor air quality and health quality standard. The quality standard defines clinical best practice for air pollution: outdoor air quality and health 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.

Strategic plans

This quality statement is taken from the air pollution: outdoor air quality and health quality standard. The quality standard defines clinical best practice for air pollution: outdoor air quality and health and should be read in full.

Quality statement

Local authorities identify in the Local Plan, local transport plan and other key strategies how they will address air pollution, including enabling zero- and low-emission travel and developing buildings and spaces to reduce exposure to air pollution.

Rationale

Local authorities should be strategic leaders of local initiatives to address air pollution, working in a coordinated way with key partners to ensure a consistent and planned approach. Identifying their approach to air pollution in the Local Plan, local transport plan and other key strategies will provide a clear framework for joined-up local action. The key components of their approach should include enabling zero- and low-emission travel (including active travel such as cycling or walking) and developing buildings and spaces to reduce exposure to air pollution.

Quality measures

Structure
a) Evidence that local authorities identify in the Local Plan, local transport plan and other key strategies how they will address air pollution, including who is responsible for delivering key actions.
Data source: Local data collection, for example, a review of actions to improve air quality is included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report.
b) Evidence that local authorities identify in the Local Plan, local transport plan and other key strategies how they will encourage and enable active travel.
Data source: Local data collection, for example, a review of actions to improve air quality is included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report.
c) Evidence that local authorities identify in the Local Plan, local transport plan and other key strategies how they will encourage and enable travel by zero- and low-emission vehicles.
Data source: Local data collection, for example, a review of actions to improve air quality is included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report.
d) Evidence that local authorities identify in the Local Plan, local transport plan and other key strategies how they will develop buildings and spaces to reduce exposure to air pollution.
Data source: Local data collection, for example, a review of actions to improve air quality is included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report.
e) Evidence that local authorities identify key actions to address air pollution and monitor progress against them.
Data source: Local data collection, for example, progress on actions to improve air quality is included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report.
Outcome
a) Proportion of journeys made by local residents that are by walking, cycling, public transport or zero- or low-emission vehicles.
Data source: Local data collection, for example, survey of residents. Data for local authorities from the Department for Transport National Travel Survey are available under special licence.
b) Annual and hourly mean concentrations for nitrogen dioxide (NO2).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.
c) Annual and daily mean concentrations for particulate matter of 10 micrometres or less in diameter (PM10).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.
d) Annual mean concentration for fine particulate matter of 2.5 micrometres or less in diameter (PM2.5).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.

What the quality statement means for different audiences

Local authorities work with partners to ensure the Local Plan, local transport plan, and other key strategies identify the approach to addressing air pollution, including enabling zero- and low-emission travel and developing buildings and spaces to reduce exposure to air pollution. Local authorities work together to prevent migration of traffic and emissions to other communities, which may result in areas of poor air quality.
People in the community know that their local authority and other local organisations are working together to protect them from the effects of air pollution.

Source guidance

Air pollution: outdoor air quality and health (2017) NICE guideline NG70, recommendations 1.1.1, 1.1.2 and 1.1.3

Definitions of terms used in this quality statement

Local authorities
All tiers of local government including county, district and unitary authorities, as well as regional bodies and transport authorities.
[NICE’s guideline on air pollution: outdoor air quality and health, recommendation 1.1.1]
Other key strategies
Relevant local strategies, such as the air quality action plan, commissioning and procurement strategy, core strategy, environment strategy, and health and wellbeing strategy.
[NICE’s guideline on air pollution: outdoor air quality and health, recommendation 1.1.1 and expert opinion]
Zero- and low-emission travel
Includes cycling and walking; travel by zero- and low-emission vehicles such as electric cars, buses, bikes and pedal cycles; and car sharing schemes or clubs.
[Adapted from NICE’s guideline on air pollution: outdoor air quality and health, recommendation 1.1.1 and terms used in this guideline]
Developing buildings and spaces to reduce exposure to air pollution
This could include:
  • siting and designing new buildings, facilities and estates to reduce the need for motorised travel
  • minimising the exposure of vulnerable groups to air pollution by not siting buildings (such as schools, nurseries and care homes) in areas where pollution levels will be high
  • siting living accommodation away from roadsides
  • avoiding the creation of street and building configurations (such as deep street canyons) that encourage pollution to build up where people spend time
  • including landscape features such as appropriate species of trees and vegetation in open spaces or as 'green' walls or roofs where this does not restrict ventilation
  • considering how structures such as buildings and other physical barriers will affect the distribution of air pollutants.
[NICE’s guideline on air pollution: outdoor air quality and health, recommendation 1.1.2]

Equality and diversity considerations

Local authorities should ensure that strategic plans identify areas where air pollution is highest and, in particular, locations where people who are vulnerable to air pollution may be exposed to high levels of air pollution, such as schools, nurseries, hospitals and care homes, so that targeted approaches can be put in place.
Local authorities should ensure that they assess the impact on vulnerable groups if local charges on certain classes of vehicle in clean air zones are proposed. If necessary, actions to mitigate the impact of charges on specific groups should be identified.

Planning applications

This quality statement is taken from the air pollution: outdoor air quality and health quality standard. The quality standard defines clinical best practice for air pollution: outdoor air quality and health and should be read in full.

Quality statement

Local planning authorities assess proposals to minimise and mitigate road-traffic-related air pollution in planning applications for major developments.

Rationale

The built environment can affect the emission of road-traffic-related air pollutants by influencing how and how much people travel, for example, by ensuring good connections to walking and cycling networks. Buildings can affect the way air pollutants are dispersed through street design and the resulting impact on air flow. Addressing air pollution at the planning stage for major developments may reduce the need for more expensive remedial action at a later stage. It can also help to maintain people’s health and wellbeing during and after construction. Assessing proposals to minimise and mitigate road-traffic-related air pollution will help to ensure they are robust and evidence based.

Quality measures

Structure
a) Evidence of local processes and guidance that ensure planning applications for major developments include proposals to minimise and mitigate road-traffic-related air pollution.
Data source: Local data collection, for example, review of supplementary planning guidance.
b) Evidence of a local framework for assessing proposals to minimise and mitigate road-traffic-related air pollution in planning applications for major developments.
Data source: Local data collection, for example, review of supplementary planning guidance.
Process
Proportion of planning applications for major developments granted permission with conditions or obligations to minimise and mitigate road-traffic-related air pollution.
Numerator – the number in the denominator with conditions or obligations to minimise and mitigate road-traffic-related air pollution.
Denominator – the number of planning applications for major developments granted permission.
Data source: Local data collection, for example, local planning application system.
Outcome
a) Proportion of journeys made by local residents that are by walking, cycling, public transport or zero- or low-emission vehicles.
Data source: Local data collection, for example, survey of residents. Data for local authorities from the Department for Transport National Travel Survey are available under special licence.
b) Annual and hourly mean concentrations for nitrogen dioxide (NO2).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.
c) Annual and daily mean concentrations for particulate matter of 10 micrometres or less in diameter (PM10).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.
d) Annual mean concentration for fine particulate matter of 2.5 micrometres or less in diameter (PM2.5).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.

What the quality statement means for different audiences

Local planning authorities ensure planning applications for major developments include proposals to minimise and mitigate road-traffic-related air pollution during and after construction. Local planning authorities provide guidance for applicants and have a clear framework for assessing proposals in line with the Local Plan, local transport plan and other key strategies. Local guidance should make it clear that proposals to minimise or mitigate road-traffic-related air pollution must be evidence based. Local planning authorities monitor compliance with planning conditions or obligations to minimise and mitigate road-traffic-related air pollution.
Local authority planning officers assess proposals to minimise and mitigate road-traffic-related air pollution in planning applications for major developments using an agreed local framework to ensure they are evidence based. Local authority planning officers encourage applicants to modify their planning applications if necessary, to include evidence-based approaches to minimise or mitigate road-traffic-related air pollution.
Planning applicants for major developments know that the local planning authority will assess proposals to minimise and mitigate road-traffic-related air pollution in planning applications to ensure they are evidence based. Planning applicants can get information on what the local planning authority is looking for and how the proposals will be assessed. Planning applicants for major developments modify their application to improve the approach to minimising or mitigating road-traffic-related air pollution if required by the local authority.
People in the community know that their local planning authorities require developers to show how they will minimise road-traffic-related air pollution and improve local air quality around big building projects when they apply for planning permission. This is to help protect local people from the effects of air pollution on their health.

Source guidance

Definitions of terms used in this quality statement

Major developments
Development involving any one or more of the following:
  • the winning and working of minerals or the use of land for mineral-working deposits
  • waste development
  • the provision of dwelling houses where:
    • the number of dwelling houses to be provided is 10 or more or
    • the development is to be carried out on a site having an area of 0.5 hectares or more and the number of dwelling houses is not known
  • the provision of a building or buildings where the floor space to be created by the development is 1,000 square metres or more or
  • development carried out on a site having an area of 1 hectare or more.

Equality and diversity considerations

Local planning authorities should ensure that proposals to encourage active travel in planning applications for major developments are accessible to people with limited mobility or disabilities.

Reducing emissions from public sector vehicle fleets

This quality statement is taken from the air pollution: outdoor air quality and health quality standard. The quality standard defines clinical best practice for air pollution: outdoor air quality and health and should be read in full.

Quality statement

Public sector organisations reduce emissions from their vehicle fleets to address air pollution.

Rationale

The public sector fleet is substantial and includes various vehicle types, some of which are highly polluting. Reducing emissions from public sector vehicle fleets will help to reduce road-traffic-related air pollution. Public sector organisations can extend their impact by commissioning transport or fleet services from organisations that reduce emissions from their vehicle fleets to address air pollution. By publicising their approach, public sector organisations can encourage organisations in other sectors to take action to reduce emissions from their vehicle fleets.

Quality measures

Structure
a) Evidence that public sector organisations identify how they will reduce emissions from their vehicle fleets to address air pollution.
Data source: Local data collection, for example, a plan to reduce fleet emissions. Organisations could use the Sustainable Development Unit’s Health Outcomes of Travel Tool (HOTT) to develop a plan.
b) Evidence that public sector organisations require commissioned transport or fleet services to reduce emissions from their vehicle fleets to address air pollution.
Data source: Local data collection, for example, commissioning specifications. Commissioning specifications could require adherence to the Department for Environment, Food and Rural Affairs’ Government Buying Standards for transport.
Outcome
a) Proportion of zero- or ultra-low-emission vehicles in public sector vehicle fleets.
Data source: Local data collection, for example, fleet statistics.
b) Overall fuel consumption for public sector vehicle fleets.
Data source: Local data collection, for example, fleet statistics.

What the quality statement means for different audiences

Service providers (such as local authorities, NHS trusts, police and fire and rescue services) develop a plan for how they will reduce emissions from their vehicle fleet to address air pollution and monitor the impact of the plan on vehicle type and total fleet CO2 emissions. Providers consider a range of approaches including:
  • replacing vehicles with zero- or ultra-low-emission vehicles over time
  • incentives to lease zero- or ultra-low-emission vehicles
  • training drivers to change their driving style
  • consolidating and sharing vehicles to ensure efficient use
  • action to minimise congestion caused by delivery schedules
  • specifying emission standards for private hire and other licensed vehicles.
Public sector fleet managers support the development and monitoring of a plan to reduce emissions from the vehicle fleet to address air pollution. Public sector fleet managers ensure that staff are aware of the plan and take action in line with the priorities identified.
Commissioners (such as local authorities, clinical commissioning groups, NHS England, and police and crime commissioners) ensure that commissioned transport or fleet services have a plan for how they will reduce emissions from their vehicle fleet to address air pollution and ensure providers monitor the impact of their plan on vehicle type and total fleet CO2 emissions.
People in the community know that public sector organisations are working to reduce pollution from their vehicles. This will help to reduce local air pollution and protect people from the effects on their health.

Source guidance

Air pollution: outdoor air quality and health (2017) NICE guideline NG70, recommendations 1.4.1, 1.4.2, 1.4.3 and 1.4.6

Advice for people with chronic respiratory or cardiovascular conditions

This quality statement is taken from the air pollution: outdoor air quality and health quality standard. The quality standard defines clinical best practice for air pollution: outdoor air quality and health and should be read in full.

Quality statement

Children, young people and adults with chronic respiratory or cardiovascular conditions are given advice at routine health appointments on what to do when outdoor air quality is poor.

Rationale

Periods of poor air quality are associated with adverse health effects, including asthma attacks, reduced lung function, and increased mortality and admissions to hospital. Providing advice to children, young people and adults with chronic respiratory or cardiovascular conditions (and their families or carers, if appropriate) at routine health appointments will support self-management, improve their awareness of how to protect themselves when outdoor air quality is poor and prevent their condition escalating.

Quality measures

Structure
a) Evidence that healthcare professionals carrying out routine health appointments with children, young people and adults with chronic respiratory or cardiovascular conditions are aware of the advice they should provide on what to do when outdoor air quality is poor.
Data source: Local data collection, for example, training records.
b) Evidence of local processes to ensure that children, young people and adults with chronic respiratory or cardiovascular conditions attending routine health appointments are given advice on what to do when outdoor air quality is poor.
Data source: Local data collection, for example, service protocols.
Process
Proportion of children, young people and adults with chronic respiratory or cardiovascular conditions attending a routine health appointment that were given advice on what to do when outdoor air quality is poor.
Numerator – the number in the denominator that were given advice on what to do when outdoor air quality is poor.
Denominator – the number of children, young people and adults with chronic respiratory or cardiovascular conditions attending a routine health appointment.
Data source: Local data collection, for example, audit of patient records.
Outcome
a) Level of awareness among children, young people and adults with chronic respiratory or cardiovascular conditions on what to do when outdoor air quality is poor.
Data source: Local data collection, for example, survey of children, young people and adults with chronic respiratory or cardiovascular conditions.
b) Rate of hospital attendance or admission for respiratory or cardiovascular exacerbations.
Data source: NHS Digital’s Hospital Episode Statistics includes data on admissions and A&E attendances for asthma attacks, acute chronic obstructive pulmonary disease exacerbations, heart attacks, strokes, heart failure and angina attacks.

What the quality statement means for different audiences

Service providers (such as general practices, community health services, hospitals and community pharmacies) ensure that healthcare professionals are aware that information on air quality is available, what it means and what actions are recommended. Service providers ensure that processes are in place to provide advice on what to do when outdoor air quality is poor to children, young people and adults with chronic respiratory or cardiovascular conditions (and their families or carers, if appropriate) at routine health appointments. Providers ensure that advice includes how to find out when outdoor air quality is expected to be poor such as from the Department for Environment, Food and Rural Affairs’ Daily Air Quality Index.
Healthcare professionals (such as doctors, nurses, healthcare assistants and pharmacists) provide advice on what to do when outdoor air quality is poor to children, young people and adults with chronic respiratory or cardiovascular conditions who are attending a routine health appointment (and their families and carers, if appropriate). They also provide information on how to find out when outdoor air quality is expected to be poor, for example using the Department for Environment, Food and Rural Affairs’ Daily Air Quality Index.
Commissioners (such as clinical commissioning groups and NHS England) commission services that provide advice on what to do when outdoor air quality is poor to children, young people and adults (and their families and carers, if appropriate) at routine health appointments.
People with long-term breathing or heart conditions (and their family and carers, if appropriate) are given advice at routine health appointments on what to do when outdoor air quality is poor and how to find out when it is likely to be poor.

Source guidance

Definitions of terms used in this quality statement

Routine health appointments
Annual reviews and other appointments focused on supporting management of chronic respiratory or cardiovascular conditions.
[Expert opinion]
Advice on what to do when outdoor air quality is poor
Advice should include how to minimise exposure to outdoor air pollution and manage any related symptoms such as:
  • Avoiding or reducing strenuous activity outside, especially in highly polluted locations such as busy streets, and particularly if experiencing symptoms such as sore eyes, a cough or sore throat.
  • Using an asthma reliever inhaler more often, as needed.
  • Closing external doors and windows facing a busy street at times when traffic is heavy or congested to help stop highly polluted air getting in.
[NICE’s guideline on air pollution: outdoor air quality and health, recommendation 1.7.7 and the Department for Environment, Food and Rural Affairs’ Daily Air Quality Index]
Poor outdoor air quality
The Daily Air Quality Index describes air pollution on a scale of 1 to 10 and is divided into 4 bands from low to very high. Health effects may occur when air pollution is moderate (4 to 6), high (7 to 9) or very high (10).
[The Department for Environment, Food and Rural Affairs’ Daily Air Quality Index]

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 has written information for the public on each of the following topics.

Pathway information

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.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services 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 guideline should be interpreted in a way that would be inconsistent with complying 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.

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.

MiraQ for assessing graft flow during coronary artery bypass graft surgery

The following recommendations are from NICE medical technologies guidance on MiraQ for assessing graft flow during coronary artery bypass graft surgery.
The case for adopting the MiraQ system in the NHS for assessing graft flow during CABG surgery is supported by the evidence. The evidence suggests that intraoperative 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 MiraQ system is associated with an estimated cost saving of £141 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).

Medtech innovation briefings

NICE has published medtech innovation briefings on:

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: February 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

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