Clinician referrals for stress echocardiography: are we compliant with the NICE guidelines?
Echo Research & Practice volume 1, pages 17–21 (2014)
Accurate diagnosis of stable angina is of paramount importance, and where possible, this should be based on clinical history. In cases of uncertainty, the National Institute for Health and Care Excellence (NICE) provides a framework for assisting diagnosis based on pre-test likelihood (PTL) of coronary artery disease. Functional testing such as stress echocardiography (SE) is recommended as a first-line investigation in patients with PTL of 30–60%. This study evaluated hospital clinicians’ adherence to this recommendation. A prospective analysis of patients referred for SE at a district general hospital between March and May 2013 was performed. Data were extracted from an electronic database of SE reports and medical notes. A total of 193 patients were assessed. The most common PTL was 61–90%, accounting for 40% of the cohort. Of them, 14% had a PTL of 30–60%. Of these, 15% had positive SE; 57% described non-anginal pain, as defined by NICE, of whom only nine cases had SE positivity. None of these patients required revascularisation. Findings suggest that SE is being used in a much broader selection group than advocated by NICE. This may often be for its exclusion value rather than to stratify risk. Although utility may be justified in high-risk patients to avoid proceeding directly to invasive angiography, SE appears to add little in those with non-anginal pain and with low PTL. Greater focus should be directed towards characterisation of symptoms, which may negate the need for subsequent investigation.
Nilsson S, Scheike M, Engblom D, Karlsson LG, Molstad S, Akerlind I, Ortoft K & Nylander E 2003 Chest pain and ischaemic heart disease in primary care. British Journal of General Practice 53 378–382.
Klinkman MS, Stevens D & Gorenflo DW 1994 Episodes of care for chest pain: a preliminary report from MIRNET. Michigan Research Network. Journal of Family Practice 38 345–352.
Department of Health 2000 National Service Framework for Coronary Heart Disease. In National Service Frameworks. Department of Health: London, UK. (available at: https://www.gov.uk/government/publications/quality-standards-for-coronary-heart-disease-care; accessed 16 April 2014)
National Institute for Health and Care Excellence 2010 Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin (CG95). NICE: London, UK (available at: http://www.nice.org.uk/guidance/CG95; accessed 24 April 2014).
Diamond GA, Staniloff HM, Forrester JS, Pollock BH & Swan HJ 1983 Computer-assisted diagnosis in the noninvasive evaluation of patients with suspected coronary artery disease. Journal of the American College of Cardiology 1 444–455. doi:10.1016/S0735-1097(83)80072-2
Sharples L, Hughes V, Crean A, Dyer M, Buxton M, Goldsmith K & Stone D 2007 Cost-effectiveness of functional cardiac testing in the diagnosis and management of coronary artery disease: a randomised controlled trial. The CECaT trial. Health Technology Assessment 11 iii–iv, ix–115.
National Institute for Health and Care Excellence 2011 Management of stable angina (CG126). NICE: London, UK (available at: http://www.nice.org.uk/guidance/CG126; accessed 24 April 2014).
Pryor DB, Shaw L, McCants CB, Lee KL, Mark DB, Harrell FE Jr, Muhlbaier LH & Califf RM 1993 Value of the history and physical in identifying patients at increased risk for coronary artery disease. Annals of Internal Medicine 118 81–90. doi:10.7326/0003-4819-118-2-199301150-00001
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Patel, P.A., Ravi, K.A., Ripley, D.P. et al. Clinician referrals for stress echocardiography: are we compliant with the NICE guidelines?. Echo Res Pract 1, 17–21 (2014). https://doi.org/10.1530/ERP-14-0028
- stress echocardiography
- stable angina
- chest pain