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The paper by Patterson et al1 illustrates why the National Institute of Health and Care Excellence (NICE) and ESC guidelines2 ,3 recommend no non-invasive testing in patients presenting with undifferentiated chest pain in whom a non-cardiac cause is suspected or the probability of coronary artery disease (CAD) is judged to be very low (NICE <10%, ESC <15%). Table 5 shows there were 351 such patients, of whom 24 were subsequently diagnosed with CAD. Even if we accept that the chest pain in all 24 of these ‘false-negative’ cases was in fact caused by myocardial ischaemia, this is equivalent to a diagnostic sensitivity of 93% for clinical judgement in ruling out coronary disease, better than could be achieved by exercise electrocardiography or perfusion imaging in such a low-risk population.4
It is unclear from the manuscript exactly how ‘the subsequent CAD diagnosis’ was determined and how sound was that determination. There were only 11 hospital admissions with ‘angina’, so it presumably involved some form of non-invasive testing in most cases. The fact that CAD was ‘excluded’ or ‘inconclusive’ in nearly all (>90%) of these patients is entirely predictable given the initial clinical diagnosis of non-cardiac chest pain or low probability of CAD. This begs the question what contribution the testing made to patient care? Certainly, the tests were unhelpful in failing to prevent six major adverse cardiac events (MACE) events, although it is hard to know whether this 1.7% event rate should be seen as a cause for ‘alarm’.
Finally, Patterson et al warn against using the NICE guidance to “justify excluding (low risk) patients from further investigation if CAD is still suspected based on all available clinical information”. There was no intention that the guideline should be used in this way but a more selective approach to investigation than apparently used by Patterson et al is surely needed to address increasing concerns about the overuse of non-invasive diagnostic tests in patients with chest pain.5
Competing interests I chaired the NICE guideline group: Chest pain of recent onset: Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. NICE guidelines [CG95] Published date: March 2010. http://www.nice.org.uk
Provenance and peer review Not commissioned; internally peer reviewed.
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