• EBM
• coronary angiography
• acute coronary syndrome
• angina treatment
• coronary artery disease (CAD)

The NICE guidance on chest pain provides a structured and evidence-based approach to the diagnosis and triage of patients with chest pain and provides a series of improvements on the status quo.1 However, the challenge is the high prevalence of occult vascular disease in our community, especially in older people and at younger ages in men than in women. There is also a high prevalence of chest pain (20%-40% of the population)2–4 but this is frequently non-cardiac in origin. Among those presenting to their primary care doctor with chest pain, the final diagnosis was not ischaemic heart disease in 83%.3 Nevertheless, because of the high prevalence of asymptomatic coronary disease there may be an unintended consequence: detection of incidental non-obstructive coronary disease. This non-obstructive coronary disease may not have been responsible for the symptoms and may “convert” an individual into a cardiac patient. Further, do we have good evidence that defining the anatomy with CT and angiography in those with non-obstructive disease will change the secondary prevention treatments that should be provided based on the patient's risk factors? From a professional and economic viewpoint we must also consider the implications for changes in clinical practice and the increased demands on finite human and economic resources.

Strengths of the guidance include the emphasis on establishing an early and accurate diagnosis based on clinical, electrocardiographic and biomarker assessments among those presenting with suspected cardiac chest pain (see page 974).5 Appropriately, there is emphasis on very early identification of ST elevation infarction and on the remainder of acute coronary syndromes (in one diagnostic pathway) and on managing those with stable angina (second diagnostic pathway). The subsequent management of these conditions is dealt with in separate NICE guidance.6 7 The NICE guidance on chest pain also emphasises …