Skip to main content
Download PDF

What’s the risk? Assessment of patients with stable chest pain

Echo Research & Practice volume 2, pages 41–48 (2015)Cite this article

Abstract

In 2010, the National Institute for Heath and Clinical Excellence published guidelines for the management of stable chest pain of recent onset. Implementation has occurred to various degrees throughout the NHS; however, its effectiveness has yet to be proved. A retrospective study was undertaken to assess the impact and relevance of this guideline, comparing the estimated risk of coronary artery disease (CAD) with angiographic outcomes. Findings were compared with the recently published equivalent European guideline. A total of 457 patients who attended a Rapid Access Chest Pain Clinic were retrospectively reviewed. CAD risk was assessed according to NICE guidelines and patients were separated into typical, atypical and non-anginal chest pain groups. Risk stratification using typicality of symptoms in conjunction with NICE risk scoring and exercise tolerance testing was used to determine the best clinical course for each patient. The results include non-anginal chest pain–92% discharged without needing further testing; atypical angina–15% discharged, 40% referred for stress echocardiography, 35% referred for angiogram and significant CAD revealed in 8%; typical angina–4% discharged, 19% referred for stress echocardiography, 71% referred for angiogram and 40% demonstrated CAD. Both guidelines appear to overestimate the risk of CAD leading to an excessive number of coronary angiograms being undertaken to investigate patients with typical or atypical sounding angina, with a low pick up rate of CAD. Given the high negative predictive value of stress echocardiography and the confidence this brings, there is much scope for expanding its use and potentially reduce the numbers going for invasive angiography.

References

  1. Timmis A, Skinner J, Adams P, Ashcroft J, Clark L, Coulden R, Hemingway H, James C, Jarman H, Kendall J et al. Chest Pain of Recent Onset: Assessment and Diagnosis of Recent Onset Chest Pain or Discomfort of Suspected Cardiac Origin. Manchester, UK: National Collaborating Centre for Acute and Chronic Conditions/National Institute for Health and Clinical Excellence, 2010. (available at: https://www.nice.org.uk/guidance/cg95)

    Google Scholar 

  2. 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)

    Article  CAS  Google Scholar 

  3. Greater Manchester and Cheshire Cardiac and Stroke Network. Pathways for Cardiology Symptoms in Primary Care. Manchester, UK: GMCCSN, 2011. (available at: http://www.gmccsn.nhs.uk/files/9413/5246/5334/Pathways_for_Cardiology_Symptoms_in_Primary_Care.pdf)

    Google Scholar 

  4. Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, Bugiardini R, Crea F, Cuisset T, Di Mario C et al. 2013 ESC guidelines on the management of stable coronary artery disease. The Task Force on the management of stable coronary artery disease of the European Society of Cardiology. European Heart Journal 34 2949–3003. (doi:10.1093/eurheartj/eht310.P4876)

    Article  Google Scholar 

  5. Genders TS, Steyerberg EW, Alkadhi H, Leschka S, Desbiolles L, Nieman K, Galema TW, Meijboom WB, Mollet NR, de Feyter PJ et al. 2011 A clinical prediction rule for the diagnosis of coronary artery disease: validation, updating, and extension. European Heart Journal 32 1316–1330. (doi:10.1093/eurheartj/ehr014)

    Article  Google Scholar 

  6. Khan JM, Harrison R, Schnaar C, Dugan C, Ramabala V, Langford E 2014 Do NICE tables overestimate the prevalence of significant CAD? British Journal of Cardiology 21 75 (doi:10.5837/bjc.2014.017)

    Google Scholar 

  7. Bruce RA, Hornstein TR 1969 Exercise stress testing in evaluation of patients with ischemic heart disease. Progress in Cardiovascular Diseases 11 371–390. (doi:10.1016/0033-0620(69)90027-9)

    Article  CAS  Google Scholar 

  8. Genders TS, Steyerberg EW, Hunink MG, Nieman K, Galema TW, Mollet NR, de Feyter PJ, Krestin GP, Alkadhi H, Leschka S et al. 2012 Prediction model to estimate presence of coronary artery disease: retrospective pooled analysis of existing cohorts. BMJ 344 e3485 (doi:10.1136/bmj.e3485)

    Article  Google Scholar 

  9. Murray CJ, Richards MA, Newton JN, Fenton KA, Anderson HR, Atkinson C, Bennett D, Bernabé E, Blencowe H, Bourne R et al. 2013 UK healthperformance: findings of the Global Burden of Disease Study 2010. Lancet 381 997–1020. (doi:10.1016/S0140-6736(13)60355-4)

    Article  Google Scholar 

  10. Scarborough P, Wickramasinghe K, Bhatnagar P, Rayner M. Trends in coronary heart disease, 1961–2011. London, UK: British Heart Foundation, 2011. (available at: https://www.bhf.org.uk/~/media/files/research/heart-statistics/bhf-trends-in-coronary-heart-disease.pdf)

    Google Scholar 

  11. Chow CK, Pell AC, Walker A, O’Dowd C, Dominiczak AF, Pell JP 2007 Families of patients with premature coronary heart disease: an obvious but neglected target for primary prevention. BMJ 335 481–485. (doi:10.1136/bmj.39253.577859.BE)

    Article  CAS  Google Scholar 

Download references

Funding

This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

Author information

Authors and Affiliations

  1. Cardio-Respiratory Department, Macclesfield District General Hospital, Victoria Road, Macclesfield, SK10 3BL, UK

    Arzu Cubukcu PhD FRCP, Ian Murray BSc & Simon Anderson BSc

Authors
  1. Arzu Cubukcu PhD FRCP
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ian Murray BSc
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Simon Anderson BSc
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Arzu Cubukcu PhD FRCP.

Rights and permissions

This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Cubukcu, A., Murray, I. & Anderson, S. What’s the risk? Assessment of patients with stable chest pain. Echo Res Pract 2, 41–48 (2015). https://doi.org/10.1530/ERP-14-0110

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1530/ERP-14-0110

Key Words

  • coronary artery disease
  • risk stratification
  • stress echocardiography
  • coronary angiography

Echo Research & Practice

ISSN: 2055-0464