In the 2016 update of the stable chest pain guideline, the National Institute for Health and Care Excellence (NICE) has made radical changes to the diagnostic paradigm that it—like other international guidelines—had previously placed at the centre of its recommendations. No longer are quantitative assessments of the disease probability considered necessary to determine the need for diagnostic testing and the choice of test. Instead, the recommendation is for no diagnostic testing if chest pain is judged to be ‘non-anginal’ and CT coronary angiography (CTCA) in patients with ‘typical’ or ‘atypical’ chest pain with additional perfusion imaging only if there is uncertainty about the functional significance of coronary lesions. The new emphasis on anatomical—as opposed to functional—testing is driven in large part by cost-effectiveness analysis and despite inevitable resource implications NICE calculates that annual savings for the population of England will be significant. In making CTCA the default diagnostic testing strategy in its updated chest pain guideline, NICE has responded emphatically to calls from trialists for CTCA to have a greater role in the diagnostic pathway of patients with suspected angina.
- Advanced cardiac imaging
- Chronic coronary disease
- Cardiac computer tomographic (CT) imaging
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Contributors Professor AT wrote the original version of this paper from start to finish. He also helped with the revisions. Professor CAR developed many of the revisions and helped rewrite the revised manuscript.
Competing interests Prof Adam Timmis NICE guidelines [CG95] Chest pain of recent onset: Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. 2010 (Chair) NICE guidelines [CG95]. Chest pain of recent onset guideline update group 2016 (topic expert) Prof Carl Roobottom NICE guidelines [CG95]. Chest pain of recent onset guideline update group 2016 (topic expert).
Provenance and peer review Commissioned; externally peer reviewed.