Clinical outcomes when applying NICE guidance for the investigation of recent-onset chest pain to a rapid-access chest pain clinic population.

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.

The feasibility of nurse-led assessment in acute chest pain admissions by means of coronary computed tomography.

BACKGROUND: Cardiac computed tomography (CCT) is a non-invasive imaging technique for the diagnosis of coronary artery disease (CAD). The National Institute for Health and Clinical Excellence (NICE) recommend CCT for selected patients in the assessment of chest pain of recent onset. AIMS: To assess the feasibility and utility of CCT in a nurse-led, protocol-based assessment of chest pain. METHODS: Patients admitted over 4 months with suspected angina were assessed for eligibility for CCT by a specialist nurse. Eligibility was defined by: a likelihood of CAD < 90%, no features of acute coronary syndrome, no contra-indications to the scanning process, and the ability to give written consent. An age and sex-matched historical cohort (for whom CCT was unavailable) was compared with the CCT cohort with regard to the diagnosis or exclusion of CAD at 3 months post-discharge from hospital. RESULTS: Of 198 patients admitted, 98 were identified as eligible for CCT. Of these, 37 were recommended for alternative management on cardiologist review, 18 declined consent, 23 were unable to be scanned within 24 h prior to discharge and 14 underwent CCT. CAD was diagnosed or excluded in 14/14 patients undergoing CCT. CAD was diagnosed or excluded in 11/14 patients investigated without CCT, leaving 3/14 patients with no clear diagnosis. CONCLUSION: This study suggests nurses may be trained to assess patients for CCT within agreed protocols. In the UK it is likely these protocols will be based on NICE guidance. Despite potential diagnostic utility, CCT appears likely to form a small percentage of cardiac investigations undertaken.

Early warning systems in the UK: variation in content and implementation strategy has implications for a NHS early warning system.

The Royal College of Physicians report Acute medical care: the right person, in the right setting--first time advocates the introduction of a standardised NHS Early Warning Score (NEWS). Recommendations for the optimum scoring system have been released by NHS Quality Improvement Scotland (NHS QIS) and the National Institute for Health and Clinical Excellence (NICE). This study reviewed clinical practice in London and Scotland against national guidelines. All hospitals responsible for acute medical admissions completed a telephone survey (n = 25 London; n = 23 Scotland). All used an early warning system at point of entry to care. Eleven different systems were used in London and five in Scotland. Forty per cent of London hospitals and 70% of Scottish hospitals incorporated the minimum data set recommended by NICE. Overall, Scotland was closer to achieving standardisation. If NEWS is implemented, consideration of the NHS QIS approach may support a more consistent response.