Abstract
The National Institute for Health and Care Excellence (NICE) provides independent
evidence-based guidance for England's National Health Service. Its 2010 guideline
for the “assessment and diagnosis of recent onset chest pain or discomfort of suspected
cardiac origin” (CG95) recommended a variety of first-line investigations in stable
patients, depending on the pre-test probability (PTP) of obstructive coronary artery
disease (CAD). Following a limited review, NICE produced an updated version of CG95
in 2016. Formal calculation of PTP is no longer advised. Coronary computed tomographic
angiography (CCTA) is recommended as the first-line investigation for all patients with angina (or non-anginal pain but an abnormal electrocardiogram) and
no prior CAD, with second-line functional imaging if the CCTA is equivocal.
Notwithstanding some controversies regarding NICE's methodology, the updated version
of CG95 can be justified on several levels. The focus on angina reflects evidence
that patients with non-anginal pain have a similar prevalence of CAD to an asymptomatic
population, and may not benefit from further investigation. The elimination of PTP
is reasonable in patients required to have cardiac-sounding (anginal) symptoms. The
ability of CCTA to identify non-obstructive atheroma, invisible to functional testing,
might lead to improved medical treatment. Conversely the argument sometimes made for
first-line functional testing, that ischemia-guided coronary revascularization leads
to improved outcomes, has little hard evidence to support it. The performance of a
separate functional test following equivocal CCTA may improve diagnostic specificity,
and similar information is now obtainable from the CT study itself via computational
flow dynamics.
Keywords
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Article info
Publication history
Published online: September 11, 2018
Accepted:
September 9,
2018
Received in revised form:
August 23,
2018
Received:
June 29,
2018
Identification
Copyright
© 2018 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.
