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The National Institute for Health and Care Excellence update for stable chest pain: poorly reasoned and risky for patients
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  • Published on:
    The true value of the NICE guidance
    • Philip D Adamson, Clinical Research Fellow University of Edinburgh/NHS Lothian
    • Other Contributors:
      • David E Newby, BHF Professor of Cardiology

    We read with interest the Editorial on the recently updated National Institute for Health and Care Excellence (NICE) guidance for the assessment of suspected stable angina (1). The authors raise some salient points regarding the importance of careful history taking, the vexed question of the exercise ECG and the relative merits of the myriad non-invasive tests for diagnosing coronary artery disease (CAD). However, we believe they have adopted an unnecessarily alarmist tone in their criticisms and feel obliged to respond to several issues.
    Although they suggest that the assessment of pretest probability (PTP) has been disregarded, this process has merely been made implicit rather than explicit. The guidelines emphasise the pivotal importance of the clinical history and, in the setting of suspected angina, the nature of the presenting symptoms is the dominant predictor of CAD. Existing risk tables (2) show that either typical or atypical angina essentially guarantees a PTP of CAD ≥ 10%, the threshold warranting further investigation in the earlier NICE guideline. The residual clinical risk seen in patients with non-anginal symptoms is best addressed through cardiovascular screening approaches with an emphasis of lifestyle modification and primary prevention.
    Second, in arguing against the cost-effectiveness of the new approach, the authors imply that NICE are recommending “universal CTCA” which is incorrect. Non-anginal chest pain occurs in 40-60% of patients pre...

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    Conflict of Interest:
    The authors are investigators involved in the SCOT-HEART trial.