The effect of applying NICE guidelines for the investigation of stable chest pain on out-patient cardiac services in the UK

Abstract

Background: The National Institute for Health and Clinical Excellence (NICE) recently released guidelines for the investigation of chest pain of recent onset. There is no published data regarding their impact on out-patient cardiac services.

Aim: This study was undertaken to assess the likelihood of coronary artery disease (CAD) in Rapid Access Chest Pain Clinic (RACPC) patients and the resultant investigation burden if NICE guidance was applied.

Methods: Five hundred and ninety-five consecutive patients attending two RACPCs over 6 months preceding release of the NICE guidelines [51% male; median age 55 (range 22-94) years] were risk stratified using NICE criteria and the resultant investigations evaluated.

Results: One hundred and six (18%) patients had a likelihood of CAD <10%, 123 (21%) between 10% and 29%, 175 (29%) between 30% and 60%, 141 (24%) between 61% and 90% and 50 (8%) >90%. NICE would have recommended 443 (74%) patients for no cardiac investigation, 10 (2%) for cardiac computed tomography (CCT), 69 (12%) for functional cardiac testing and 73 (12%) for invasive angiography. Relative to existing practice, there would have been a trend towards reduced functional cardiac testing (-24%, P = 0.06), no significant change in CCT (43%, P = 0.436) and a significant increase in invasive angiography (508%, P < 0.001). The cost of investigations recommended by NICE would have been £15,881 greater than existing practice.

Conclusion: This study suggests patients attending RACPC will have a greater likelihood of CAD than predicted by NICE. Differences between recommended investigations and existing practice will guide investment in cardiac services. Individual hospitals should assess their RACPC cohorts prior to implementing the NICE guidelines.