title: Clinical outcomes when applying NICE guidance for the investigation of recent-onset chest pain to a rapid-access chest pain clinic population.
abstract: OBJECTIVE
  To describe the clinical outcomes of patients for whom National Institute for Health and Care Excellence (NICE) recent-onset chest pain guidance would not have recommended further investigation, compared with those of patients where further investigation would have been recommended.
  
  
  METHODS
  557 consecutive patients with recent-onset chest pain attending rapid-access chest pain clinics (RACPC) in two district general hospitals over a 9-month period were retrospectively reviewed. Likelihood of coronary artery disease (CAD) was calculated according to NICE-defined modified Diamond-Forrester criteria. Patients were categorised into those for whom NICE guidelines recommend (NICE-Y) and do not recommend (NICE-N) further investigation. Main outcome measures were subsequent diagnosis of significant CAD and major adverse cardiac events (MACE) at 6 months.
  
  
  RESULTS
  187/557 (33.6%) patients comprised NICE-Y group, with 370/557 (66.4%) in NICE-N group. 360/370 (97.3%) of NICE-N group would have been excluded from further investigation due to non-anginal chest pain. Of 92/557 (16.5%) patients subsequently diagnosed with significant CAD, 35/557 (9.5%) were from NICE-N group versus 57/557 (30.5%, p<0.0001) from NICE-Y group. Of 11 patients experiencing at least one MACE, 7/557 (1.9%) were from NICE-N group, versus 4/557 (2.1%, p=1.000) from NICE-Y group.
  
  
  CONCLUSIONS
  The rigid application of NICE chest pain guidance to a RACPC population may result in up to two-thirds of patients being excluded from further cardiac investigation. Potentially, up to 10% of these patients may subsequently be diagnosed with significant CAD, with up to 2% potentially experiencing a major adverse cardiac event.
authors.affiliation: Chelsea and Westminster Hospital, London, UK NIHR CLAHRC for Northwest London, London, UK Imperial College, London, UK.
authors.forename: Caroline Marie
authors.initials: CM
authors.lastname: Patterson
authors.affiliation: Guy's and St Thomas' Hospitals, London, UK.
authors.forename: Arjun
authors.initials: A
authors.lastname: Nair
authors.affiliation: Ealing Hospital, London, UK.
authors.forename: Nabeel
authors.initials: N
authors.lastname: Ahmed
authors.affiliation: NIHR CLAHRC for Northwest London, London, UK.
authors.forename: Leoni
authors.initials: L
authors.lastname: Bryan
authors.affiliation: Chelsea and Westminster Hospital, London, UK NIHR CLAHRC for Northwest London, London, UK Imperial College, London, UK.
authors.forename: Derek
authors.initials: D
authors.lastname: Bell
authors.affiliation: Chelsea and Westminster Hospital, London, UK Imperial College, London, UK Royal Brompton Hospital, London, UK.
authors.forename: Edward David
authors.initials: ED
authors.lastname: Nicol
mesh_terms: D000328:Adult; D000368:Aged; D002637:Chest Pain / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology / Q000503:physiopathology; D015331:Cohort Studies; D003324:Coronary Artery Disease / Q000150:complications / Q000175:diagnosis / Q000453:epidemiology / Q000503:physiopathology; D003937:Diagnosis, Differential; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008875:Middle Aged; D063868:Patient Outcome Assessment; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods / Q000706:statistics & numerical data; D012307:Risk Factors; D063189:Symptom Assessment / Q000379:methods; D006113:United Kingdom / Q000453:epidemiology
keywords: CORONARY ARTERY DISEASE