NICE Guidelines for Non-angina Chest Pain Miss a Significant Proportion of CAD Patients

Becky McCall

June 10, 2021

A substantial proportion of patients with coronary artery disease (CAD) are missed when presenting with non-anginal chest pain shows a 2-year study that followed local rather than National Institute for Health and Care Excellence (NICE) guidelines.   

Results showed that 13.3% of patients who presented to the Rapid Access Chest Pain (RACP) clinic with non-anginal chest pain had significant CAD on imaging. "By doing this audit, we’ve picked up a high proportion of patients that would have been missed," said Dr Will Chick, Wythenshawe Hospital, Manchester, presenting results of the study at the British Cardiovascular Society (BCS) virtual 2021 conference. "This imaging not only turned up patients with significant CAD but also some patients requiring early medical preventative therapy.

"The results show that NICE criteria, currently in use, could be missing a substantial number of patients with coronary artery disease who could be started on some type of therapy, if not interventional procedures," added Dr Chick speaking to Medscape News UK.

'Crude' Assessment

In 2016, guidelines from NICE defined three key features of angina: constricting discomfort in the front of the chest, neck, shoulders, jaw or arms; precipitated by physical exertion; and relieved by rest or administration of glyceryl trinitrate (GTN) within 5 minutes. If all of these three features are present then this suggests typical angina, if two features are present then it is considered atypical, and if one or no features are present then this suggests non-anginal chest pain. In the latter case, diagnostic testing is not recommended, instead clinicians should investigate for gastro-intestinal, respiratory, or musculoskeletal origins.

Anecdotally, physicians at Wythenshawe Hospital, a tertiary cardiology referral centre, noticed that large numbers of patients with non-anginal chest pain had CAD upon subsequent diagnostic imaging. For this reason, local guidelines suggested continued imaging in patients with non-anginal chest pain for CAD with a view to auditing the results, explained Dr Chick. This led to the current analysis.

"It seems that in Europe and the US there might be more detailed analyses before scoring patients and deciding who to image. Right now, the NICE guidelines seem to provide a crude way of only looking at the presence of these three features," said Dr Chick. "This might not be the best way forward."

Effective Screening of Asymptomatic Patients

Commenting on the work, Dr Piyush Jain, consultant cardiologist at West Hertfordshire Hospitals NHS Trust, said that the study demonstrates the weakness of largely subjective symptom-based risk-scoring where complex and multiple symptoms may score poorly and not qualify for further investigations. 

However, he added that, "It is difficult to justify population screening for all patients based on risk factors which is what this study hints at, more so for a healthcare system with finite resources. Arguably, shouldn't all patients be treated for appropriate risk factor modification once seen in clinic anyway? Especially when the role of intervention over optimal medical management is getting less clear cut with emerging data, even for patients with symptoms and ischaemia on testing." 

Dr Marc Dweck, British Heart Foundation fellow and consultant cardiologist at the University of Edinburgh, also commented on the study, noting that the data added to the literature suggesting there may be some benefit in using CT to guide primary prevention therapy. "This would involve the prescription of drugs such as statins and aspirin on the basis of the actual presence of coronary atherosclerosis in a given asymptomatic patient, rather than simply their risk factors." He pointed out that this question was currently being investigated in the SALTIRE 2 randomised controlled trial. "For now, the NICE guidelines work well and we should continue to follow them in the UK.

"Patients with non-cardiac chest pain are essentially asymptomatic from a heart point of view. The use of CT in this group is therefore veering into the realm of screening and is not currently recommended by the NICE guidelines," Dr Dweck added. "We need robust data to demonstrate the benefits of using CT as a screening tool in asymptomatic patients, before we can justify the added costs involved."

Audit of Patients With Non-anginal Chest Pain for CAD

The study aimed to establish the prevalence of CAD in patients with non-anginal chest pain, and to compare the prevalence of cardiovascular risk factors in those with and without CAD.

Patients, totalling 1078, who attended the RACP clinic between January 2017 and December 2019 were included providing nearly 2-years of data. Patients had one of the three NICE-specified features and therefore had non-anginal chest pain, without prior history of cardiac disease.

Investigations included first-line cardiac computed tomography (CT) with Coronary Artery Calcium Data and Reporting System (CAC-DRS) and Coronary Artery Disease - Reporting and Data System (CAD-RADS) scoring used to calculate calcium scores and luminal stenosis respectively; and second-line stress echocardiography or invasive angiography. The presence of cardiovascular risk factors was also noted on their record including their age, Qrisk2 score, diabetes, hypertension, family history of cardiovascular disease (CVD), and hypercholesterolaemia.

All 1078 patients were referred for CT coronary angiogram (CTCA). In 872, the CTCA allowed luminal analysis and CAD-RADS, and in 127 of these, subsequent stress echocardiography was performed. "In most of these, their CAD-RAD was borderline and needed stress echocardiography to establish if CAD was present," explained Dr Chick.

In 206 patients the CTCA was uninterpretable, reasons being too high calcium score to allow luminal analysis, high heart rate or poor image and contrast. Of these, 199 had a stress echocardiography instead and seven had an invasive coronary angiogram.

Dr Chick explained that CAD was considered present if the CADS-RADS score was four or more on CTCA, or the presence of stress inducible ischaemia on dobutamine or bicycle stress echo, or severe stenosis on invasive angiography.

"Importantly, 143 patients [13.3% of entire cohort] were found to have significant CAD on imaging, and 34 of these patients had revascularisation (9 by-pass and 25 PCI).”

In the 143 patients, Dr Chick compared them to those that did not have CAD (935 patients) to identify prevalence of CV risk factors including age, diabetes, hypertension, and family history of CVD. "We found that those with significant CAD were more likely to be older [<0.001], have hypertension [0.004] and a higher Qrisk2 score [<0.001]. Essentially, these findings suggest these three risk factors seems to be associated with people experiencing non-anginal chest pain that have CAD.

"Looking for the prevalence of these risk factors might be a good way forward to establish more refined guidelines for identifying patients with CAD as well as providing opportunity to start people on preventative therapies too," remarked Dr Chick.

Finally, a subset of patients was identified that upon CAC-DRS score required preventative therapy but showed no significant CAD on imaging and had a Qrisk2 score of <10%. "This finding was important because these patients were identified for medical preventative therapy and would otherwise have been missed without diagnostic testing due to their Qrisk2 score being below 10%."

Presented at the British Cardiovascular Society (BCS) 2021 virtual conference, June 7-10, 2021.

COI: None declared by any contributor.

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