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Clinical outcomes when applying NICE guidance for the investigation of recent-onset chest pain to a rapid-access chest pain clinic population
  1. Caroline Marie Patterson1,2,3,
  2. Arjun Nair4,
  3. Nabeel Ahmed5,
  4. Leoni Bryan2,
  5. Derek Bell1,2,3,
  6. Edward David Nicol1,3,6
  1. 1Chelsea and Westminster Hospital, London, UK
  2. 2NIHR CLAHRC for Northwest London, London, UK
  3. 3Imperial College, London, UK
  4. 4Guy's and St Thomas’ Hospitals, London, UK
  5. 5Ealing Hospital, London, UK
  6. 6Royal Brompton Hospital, London, UK
  1. Correspondence to Dr Edward David Nicol, Chelsea and Westminster Hospital; Imperial College; Royal Brompton Hospital, London, SW3 6NP UK; E.Nicol{at}


Objective To describe the clinical outcomes of patients for whom National Institute for Health and Care Excellence (NICE) recent-onset chest pain guidance would not have recommended further investigation, compared with those of patients where further investigation would have been recommended.

Methods 557 consecutive patients with recent-onset chest pain attending rapid-access chest pain clinics (RACPC) in two district general hospitals over a 9-month period were retrospectively reviewed. Likelihood of coronary artery disease (CAD) was calculated according to NICE-defined modified Diamond–Forrester criteria. Patients were categorised into those for whom NICE guidelines recommend (NICE-Y) and do not recommend (NICE-N) further investigation. Main outcome measures were subsequent diagnosis of significant CAD and major adverse cardiac events (MACE) at 6 months.

Results 187/557 (33.6%) patients comprised NICE-Y group, with 370/557 (66.4%) in NICE-N group. 360/370 (97.3%) of NICE-N group would have been excluded from further investigation due to non-anginal chest pain. Of 92/557 (16.5%) patients subsequently diagnosed with significant CAD, 35/557 (9.5%) were from NICE-N group versus 57/557 (30.5%, p<0.0001) from NICE-Y group. Of 11 patients experiencing at least one MACE, 7/557 (1.9%) were from NICE-N group, versus 4/557 (2.1%, p=1.000) from NICE-Y group.

Conclusions The rigid application of NICE chest pain guidance to a RACPC population may result in up to two-thirds of patients being excluded from further cardiac investigation. Potentially, up to 10% of these patients may subsequently be diagnosed with significant CAD, with up to 2% potentially experiencing a major adverse cardiac event.


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