2011;378:30. 562. Patel MR, Jneid H, Derdeyn CP, et al. Arteriotomy closure devices for cardiovascular procedures: a scientific statement from the American Heart Association. Circulation. 2010;122:1882 93. Erratum in: Circula- tion. 2010;122:e507. 563. Marso SP, Amin AP, House JA, et al. Association between use of bleed- ing avoidance strategies and risk of periprocedural bleeding among patients undergoing percutaneous coronary intervention. JAMA. 2010;303:2156 64. 564. Koreny M, Riedm ller E, Nikfardjam M, et al. Arterial puncture closing devices compared with standard manual compression after cardiac cathe- terization: systematic review and meta-analysis. JAMA. 2004;291:350 7. 565. Doyle BJ, Ting HH, Bell MR, et al. Major femoral bleeding complica- tions after percutaneous coronary intervention: incidence, predictors, and impact on long-term survival among 17,901 patients treated at the Mayo Clinic from 1994 to 2005. JACC Cardiovasc Interv. 2008;1:202 9. 566. Dauerman HL, Rao SV, Resnic FS, et al. Bleeding avoidance strategies: consensus and controversy. J Am Coll Cardiol. 2011;58:1 10. 567. Kosiborod M, McGuire DK. Glucose-lowering targets for patients with cardiovascular disease: focus on inpatient management of patients with acute coronary syndromes. Circulation. 2010;122:2736 44. 568. Pinto DS, Skolnick AH, Kirtane AJ, et al. U-shaped relationship of blood glucose with adverse outcomes among patients with ST-segment eleva- tion myocardial infarction. J Am Coll Cardiol. 2005;46:178 80. 569. Kosiborod M, Inzucchi SE, Krumholz HM, et al. Glucometrics in pa- tients hospitalized with acute myocardial infarction: defining the optimal outcomes-based measure of risk. Circulation. 2008;117:1018 27. 570. Finfer S, Chittock DR, Su SY-S, et al. Intensive versus conventional glu- cose control in critically ill patients. N Engl J Med. 2009;360:1283 97. 571. Mehta SR,Yusuf S, D az R, et al. Effect of glucose-insulin-potassium in- fusion on mortality in patients with acute ST-segment elevation myocar- dial infarction: the CREATE-ECLA randomized controlled trial. JAMA. 2005;293:437 46.


Effect of glucose-insulin-potassium in- fusion on mortality in patients with acute ST-segment elevation myocar- dial infarction: the CREATE-ECLA randomized controlled trial. JAMA. 2005;293:437 46. 572. van der Horst ICC, Zijlstra F, van t Hof AWJ, et al. Glucose-insulin- potassium infusion inpatients treated with primary angioplasty for acute myocardial infarction: the glucose-insulin-potassium study: a random- ized trial. J Am Coll Cardiol. 2003;42:784 91. 573. Selker HP, Beshansky JR, Sheehan PR, et al. Out-of-hospital administra- tion of intravenous glucose-insulin-potassium in patients with suspected acute coronary syndromes: the IMMEDIATE randomized controlled trial. JAMA. 2012;307:1925 33. 574. Newby LK, Eisenstein EL, Califf RM, et al. Cost effectiveness of early discharge after uncomplicated acute myocardial infarction. N Engl J Med. 2000;342:749 55. 575. Newby LK, Hasselblad V, Armstrong PW, et al. Time-based risk assess- ment after myocardial infarction: implications for timing of discharge and applications to medical decision-making. Eur Heart J. 2003;24:182 9. 576. Antman EM, Kuntz KM. The length of the hospital stay after myocardial infarction. N Engl J Med. 2000;342:808 10. 577. Th roux P, Waters DD, Halphen C, et al. Prognostic value of exercise testing soon after myocardial infarction. N Engl J Med. 1979;301:341 5. 578. Villella A, Maggioni AP, Villella M, et al. Prognostic significance of maximal exercise testing after myocardial infarction treated with throm- bolytic agents: the GISSI-2 data-base: Gruppo Italiano per lo Studio della Sopravvivenza Nell Infarto. Lancet. 1995;346:523 9. 579. Leppo JA, O Brien J, Rothendler JA, et al. Dipyridamole-thallium-201 scintigraphy in the prediction of future cardiac events after acute myo- cardial infarction. N Engl J Med. 1984;310:1014 8. 580. Hendel RC, Berman DS, Di Carli MF, et al.


580. Hendel RC, Berman DS, Di Carli MF, et al. ACCF/ASNC/ACR/AHA/ ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac ra- dionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the Ameri- can Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Car- diovascular Magnetic Resonance, and the Society of Nuclear Medicine. Circulation. 2009;119:e561 87. 581. Douglas PS, Garcia MJ, Haines DE, et al. ACCF/ASE/AHA/ASNC/ HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, So- ciety of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol. 2011;57:1126 66. 582. Thomas RJ, King M, Lui K, et al. AACVPR/ACCF/AHA 2010 up- date: performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services. Circulation. 2010;122:1342 50. 583. Jain A, Myers GH, Sapin PM, et al. Comparison of symptom-limited and low level exercise tolerance tests early after myocardial infarction. J Am Coll Cardiol. 1993;22:1816 20. 584. Roffi M, Wenaweser P, Windecker S, et al. Early exercise after coronary stenting is safe. J Am Coll Cardiol. 2003;42:1569 73. 585. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Prac- tice Guidelines (Committee to Update the 1997 Exercise Testing Guide- lines). Circulation. 2003;107:149 58. Erratum in: J Am Coll Cardiol. 2006;48:1731. 586. Klocke FJ, Baird MG, Lorell BH, et al.


2006;48:1731. 586. Klocke FJ, Baird MG, Lorell BH, et al. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging: executive summary: a report of the American College of Cardiology/American Heart Associa- tion Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Cardiac Radionuclide Imaging). Circulation. 2003;108:1404 18. 587. Hohnloser SH, Kuck KH, Dorian P, et al. Prophylactic use of an implant- able cardioverter-defibrillator after acute myocardial infarction. N Engl J Med. 2004;351:2481 8. 588. Steinbeck G, Andresen D, Seidl K, et al. Defibrillator implantation early after myocardial infarction. N Engl J Med. 2009;361:1427 36. 589. Moss AJ, Zareba W, Hall WJ, et al. Prophylactic implantation of a defi- brillator in patients with myocardial infarction and reduced ejection frac- tion. N Engl J Med. 2002;346:877 83. 590. Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med. 2005;352:225 37. Erratum in: N Engl J Med. 2005;352:2146. 591. Goldenberg I, Gillespie J, Moss AJ, et al. Long-term benefit of primary prevention with an implantable cardioverter-defibrillator: an extended 8-year follow-up study of the Multicenter Automatic Defibrillator Im- plantation Trial II. Circulation. 2010;122:1265 71. O Gara et al 2013 ACCF/AHA STEMI Guideline e417 592. Tracy CM, Epstein AE, Darbar D, et al. 2012 ACCF/AHA/HRS focused update of the 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Founda- tion/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. 2012;126:1784-1800. Erratum in: Circulation. 2013;127:e357 9. 593. Naylor M, Brooten D, Jones R, et al. Comprehensive discharge planning for the hospitalized elderly: a randomized clinical trial. Ann Intern Med. 1994;120:999 1006. 594. Coleman EA, Parry C, Chalmers S, et al.


1994;120:999 1006. 594. Coleman EA, Parry C, Chalmers S, et al. The care transitions interven- tion: results of a randomized controlled trial. Arch Intern Med. 2006; 166:1822 8. 595. Young W, Rewa G, Goodman SG, et al. Evaluation of a community- based inner-city disease management program for postmyocardial infarc- tion patients: a randomized controlled trial. CMAJ. 2003;169:905 10. 596. Jack BW, Chetty VK,Anthony D, et al.A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150:178 87. 597. Lapp JM, Muhlestein JB, Lapp DL, et al. Improvements in 1-year car- diovascular clinical outcomes associated with a hospital-based discharge medication program. Ann Intern Med. 2004;141:446 53. 598. Leon AS, Franklin BA, Costa F, et al. Cardiac rehabilitation and sec- ondary prevention of coronary heart disease: an American Heart As- sociation scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcom- mittee on Physical Activity), in collaboration with the American Asso- ciation of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2005;111:369 76. Erratum in: Circulation. 2005;111:1717. 599. Suaya JA, Stason WB, Ades PA, et al. Cardiac rehabilitation and survival in older coronary patients. J Am Coll Cardiol. 2009;54:25 33. 600. Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analy- sis of randomized controlled trials. Am J Med. 2004;116:682 92. 601. Goel K, Lennon RJ, Tilbury RT, et al. Impact of cardiac rehabilitation on mortality and cardiovascular events after percutaneous coronary inter- vention in the community. Circulation. 2011;123:2344 52. 602. Wilson K, Gibson N, Willan A, et al. Effect of smoking cessation on mor- tality after myocardial infarction: meta-analysis of cohort studies. Arch Intern Med. 2000;160:939 44. 603. Thomson CC, Rigotti NA.


Arch Intern Med. 2000;160:939 44. 603. Thomson CC, Rigotti NA. Hospital- and clinic-based smoking cessation interventions for smokers with cardiovascular disease. Prog Cardiovasc Dis. 2003;45:459 79. 604. Dawood N, Vaccarino V, Reid KJ, et al. Predictors of smoking cessation after a myocardial infarction: the role of institutional smoking cessation programs in improving success. Arch Intern Med. 2008;168:1961 7. 605. Shah AM, Pfeffer MA, Hartley LH, et al. Risk of all-cause mortality, re- current myocardial infarction, and heart failure hospitalization associated with smoking status following myocardial infarction with left ventricular dysfunction. Am J Cardiol. 2010;106:911 6. 606. Bernheim SM, Grady JN, Lin Z, et al. National patterns of risk-stan- dardized mortality and readmission for acute myocardial infarction and heart failure: update on publicly reported outcomes measures based on the 2010 release. Circ Cardiovasc Qual Outcomes. 2010;3:459 67. 607. Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc. 2003;51:549 55. 608. Coleman EA, Boult C. Improving the quality of transitional care for per- sons with complex care needs. J Am Geriatr Soc. 2003;51:556 7. 609. Coleman EA, Mahoney E, Parry C. Assessing the quality of preparation for posthospital care from the patient s perspective: the care transitions measure. Med Care. 2005;43:246 55. 610. Bernheim SM, Spertus JA, Reid KJ, et al. Socioeconomic disparities in outcomes after acute myocardial infarction.Am Heart J. 2007;153:313 9. 611. RahimiAR, Spertus JA, Reid KJ, et al. Financial barriers to health care and outcomes after acute myocardial infarction. JAMA. 2007;297:1063 72. 612. Smolderen KG, Spertus JA, Reid KJ, et al. The association of cogni- tive and somatic depressive symptoms with depression recognition and outcomes after myocardial infarction. Circ Cardiovasc Qual Outcomes. 2009;2:328 37. 613. Kaiser Permanente.


The association of cogni- tive and somatic depressive symptoms with depression recognition and outcomes after myocardial infarction. Circ Cardiovasc Qual Outcomes. 2009;2:328 37. 613. Kaiser Permanente. Case Study: Collaborative Cardiac Care Service Collaborative Teams Improve Cardiac Care with Health Information Technology. March 27, 2009. Available at: http://xnet.kp.org/future/ ahrstudy/032709cardiac.html. Accessed March 10, 2011. 614. Balady GJ, Williams MA, Ades PA, et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Re- habilitation, and Prevention Committee, the Council on Clinical Car- diology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2007;115:2675 82. 615. Suaya JA, Shepard DS, Normand S-LT, et al. Use of cardiac rehabilita- tion by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation. 2007;116:1653 62. 616. Snow V, Beck D, Budnitz T, et al. Transitions of care consensus policy statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society- American College of Emergency Physicians-Society of Academic Emer- gency Medicine. J Gen Intern Med. 2009;24:971 6. 617. National Quality Forum. Safe Practices for Healthcare 2010 update. Available at: http://qualityforum.org/projects/safe_practices_2010.aspx. Accessed December 9, 2010. 618. The Joint Commission. 2010 National Patient Safety Goals. Available at: http://www.jointcommission.org/standards_information/npsgs.aspx. Accessed December 9, 2010. 619. National Quality Forum. Preferred practices and performance measures for measuring and reporting care coordination. Available at: http:// qualityforum.org/projects/care_coordination.aspx. Accessed December 9, 2010. 620. Desai MM, Stauffer BD, Feringa HHH, et al. Statistical models and pa- tient predictors of readmission for acute myocardial infarction: a system- atic review. Circ Cardiovasc Qual Outcomes. 2009;2:500 7. 621. Verouden NJW, Haeck JDE, Kuijt WJ, et al.


2009;2:500 7. 621. Verouden NJW, Haeck JDE, Kuijt WJ, et al. Prediction of 1-year mortal- ity with different measures of ST-segment recovery in all-comers after primary percutaneous coronary intervention for acute myocardial infarc- tion. Circ Cardiovasc Qual Outcomes. 2010;3:522 9. 622. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/ PCNA/SCAI/STS guideline for the diagnosis and management of pa- tients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. November 20. doi:10.1161/ CIR.0b013e318277d6a0. Available at: http://circ.ahajournals.org/look- up/doi/10/1161/CIR.0b013e318277d6a0. Accessed November 20, 2012. 623. American College of Chest Physicians. Tobacco Cessation Toolkit. Available at: http://tobaccodependence.chestnet.org/. Accessed March 9, 2011. 624. Deleted in press. 625. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560 72. Erratum in: JAMA. 2003;290:197. 626. Buse JB, Ginsberg HN, Bakris GL, et al. Primary prevention of cardio- vascular diseases in people with diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes Asso- ciation. Diabetes Care. 2007;30:162 72. 627. Hunt SA, Abraham WT, Chin MH, et al. 2009 Focused update incor- porated into the ACC/AHA 2005 guidelines for the diagnosis and man- agement of heart failure in adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Prac- tice Guidelines, developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009;119:e391 479. Erratum in: Circulation. 2010;121:e258. 627a Levine GN, Steinke EE, Bakaeen FG, et al. Sexual activity and cardio- vascular disease: a scientific statement from the American Heart Associa- tion. Circulation. 2012;125:1058 72 628. Mosca L,Appel LJ, Benjamin EJ, et al.


2012;125:1058 72 628. Mosca L,Appel LJ, Benjamin EJ, et al. Evidence-based guidelines for car- diovascular disease prevention in women. Circulation. 2004;109:672 93. 629. Lichtman JH, Bigger JT Jr, Blumenthal JA, et al. Depression and coronary heart disease: recommendations for screening, referral, and treatment: a science advisory from the American Heart Association Pre- vention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research. Circulation. 2008;118:1768 75. 630. Harper SA, Fukuda K, Uyeki TM, et al. Prevention and control of in- fluenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2005;54:1 40. 631. Curry LA, Spatz E, Cherlin E, et al. What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study. Ann Intern Med. 2011;154:384 90. 632. Lambert L, Brown K, Segal E, et al. Association between timeliness of reperfusion therapy and clinical outcomes in ST-elevation myocardial in- farction. JAMA. 2010;303:2148 55. 633. STREAM (Strategic Reperfusion [With Tenecteplase and Antithrombot- ic Treatment] Early After Myocardial Infarction) Trial. 2011. ClinicalTri- als.gov identifier: NCT00623623. Available at: http://clinicaltrials.gov/ ct2/show/NCT00623623. Accessed November 1, 2010. 634. McLean S, Wild S, Connor P, et al. Treating ST elevation myocardial infarction by primary percutaneous coronary intervention, in-hospital thrombolysis and prehospital thrombolysis: an observational study of timelines and outcomes in 625 patients. Emerg Med J. 2011;28:230 6. 635. Blankenship JC, Scott TD, Skelding KA, et al. Door-to-balloon times under 90 min can be routinely achieved for patients transferred for ST- segment elevation myocardial infarction percutaneous coronary interven- tion in a rural setting. J Am Coll Cardiol. 2011;57:272 9. 636. Flynn A, Moscucci M, Share D, et al. Trends in door-to-balloon time and mortality in patients with ST-elevation myocardial infarction un- dergoing primary percutaneous coronary intervention.


Trends in door-to-balloon time and mortality in patients with ST-elevation myocardial infarction un- dergoing primary percutaneous coronary intervention. Arch Intern Med. 2010;170:1842 9. 637. Mega JL, Close SL, Wiviott SD, et al. Genetic variants in ABCB1 and CYP2C19 and cardiovascular outcomes after treatment with clopidogrel and prasugrel in the TRITON-TIMI 38 trial: a pharmacogenetic analysis. Lancet. 2010;376:1312 9. 638. Mega JL, Braunwald E, Wiviott SD, et al. Rivaroxaban in patients with a recent acute coronary syndrome. N Engl J Med. 2012;366:9 19. 639. Tricoci P, Huang Z, Held C, et al. Thrombin-receptor antagonist vora- paxar in acute coronary syndromes. N Engl J Med. 2012;366:20 33. 640. Bekkers SCAM, Yazdani SK, Virmani R, et al. Microvascular obstruc- tion: underlying pathophysiology and clinical diagnosis. J Am Coll Car- diol. 2010;55:1649 60. 641. Timmers L, Henriques JPS, de Kleijn DPV, et al. Exenatide reduces in- farct size and improves cardiac function in a porcine model of ischemia and reperfusion injury. J Am Coll Cardiol. 2009;53:501 10. 642. Wu KC. Fighting the fire of myocardial reperfusion injury: how to de- fine success? J Am Coll Cardiol. 2009;53:730 1. 643. Deleted in press. 644. Prasad A, Stone GW, Holmes DR, et al. Reperfusion injury, microvas- cular dysfunction, and cardioprotection: the dark side of reperfusion. Circulation. 2009;120:2105 12. 645. Patti G, Cannon CP, Murphy SA, et al. Clinical benefit of statin pre- treatment in patients undergoing percutaneous coronary intervention: a collaborative patient-level meta-analysis of 13 randomized studies. Cir- culation. 2011;123:1622 32. 646. Dorian P, Hohnloser SH, Thorpe KE, et al. Mechanisms underlying the lack of effect of implantable cardioverter-defibrillator therapy on mortal- ity in high-risk patients with recent myocardial infarction: insights from the Defibrillation in Acute Myocardial Infarction Trial (DINAMIT). Cir- culation. 2010;122:2645 52. 647. Terzic A, Nelson TJ. Regenerative medicine advancing health care 2020.


Terzic A, Nelson TJ. Regenerative medicine advancing health care 2020. J Am Coll Cardiol. 2010;55:2254 7. 648. Sch chinger V, Erbs S, Els sser A, et al. Intracoronary bone marrow- derived progenitor cells in acute myocardial infarction. N Engl J Med. 2006;355:1210 21. 649. Hirsch A, Nijveldt R, van der Vleuten PA, et al. Intracoronary infusion of mononuclear cells from bone marrow or peripheral blood compared with standard therapy in patients after acute myocardial infarction treated by primary percutaneous coronary intervention: results of the randomized controlled HEBE trial. Eur Heart J. 2011;32:1736 47. 650. Roncalli J, Mouquet F, Piot C, et al. Intracoronary autologous mono- nucleated bone marrow cell infusion for acute myocardial infarction: results of the randomized multicenter BONAMI trial. Eur Heart J. 2011; 32:1748 57. 651. Traverse JH, Henry TD, Ellis SG, et al. Effect of intracoronary delivery of autologous bone marrow mononuclear cells 2 to 3 weeks following acute myocardial infarction on left ventricular function: the LateTIME randomized trial. JAMA. 2011;306:2110 9. 652. Makkar RR, Smith RR, Cheng K, et al. Intracoronary cardiosphere- derived cells for heart regeneration after myocardial infarction (CADUCEUS): a prospective, randomised phase 1 trial. Lancet. 2012;379:895 904. 653. Ptaszek LM, Mansour M, Ruskin JN, et al. Towards regenerative therapy for cardiac disease. Lancet. 2012;379:933 42. 654. Janssens S, Dubois C, Bogaert J, et al. Autologous bone marrow-de- rived stem-cell transfer in patients with ST-segment elevation myo- cardial infarction: double-blind, randomised controlled trial. Lancet. 2006;367:113 21. 655. Dill T, Sch chinger V, Rolf A, et al. Intracoronary administration of bone marrow-derived progenitor cells improves left ventricular function in pa- tients at risk for adverse remodeling after acute ST-segment elevation myocardial infarction: results of the Reinfusion of Enriched Progenitor cells And Infarct Remodeling in Acute Myocardial Infarction study (RE- PAIR-AMI) cardiac magnetic resonance imaging substudy.


Intracoronary administration of bone marrow-derived progenitor cells improves left ventricular function in pa- tients at risk for adverse remodeling after acute ST-segment elevation myocardial infarction: results of the Reinfusion of Enriched Progenitor cells And Infarct Remodeling in Acute Myocardial Infarction study (RE- PAIR-AMI) cardiac magnetic resonance imaging substudy. Am Heart J. 2009;157:541 7. 656. Bolli R, Chugh AR, D Amario D, et al. Cardiac stem cells in patients with ischaemic cardiomyopathy (SCIPIO): initial results of a randomised phase 1 trial. Lancet. 2011;378:1847 57. Key Words: AHA Scientific Statements anticoagulants antiplatelets door-to-balloon fibrinolysis percutaneous coronary intervention reperfusion ST-elevation myocardial infarction thrombolysis O Gara et al 2013 ACCF/AHA STEMI Guideline e419 Appendix 1.


Key Words: AHA Scientific Statements anticoagulants antiplatelets door-to-balloon fibrinolysis percutaneous coronary intervention reperfusion ST-elevation myocardial infarction thrombolysis O Gara et al 2013 ACCF/AHA STEMI Guideline e419 Appendix 1. Author Relationships With Industry and Other Entities (Relevant) 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction Committee Member Employment Consultant Speaker s Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Voting Recusals by Section* Patrick T. O Gara, Chair Harvard Medical School Professor of Medicine None None None None None None None Frederick G. Kushner, Vice Chair Tulane University School of Medicine Clinical Professor of Medicine; Heart Clinic of Louisiana Medical Director None None None None Novartis None 8.1 Deborah D. Ascheim Mount Sinai School of Medicine Associate Professor; InCHOIR Clinical Director of Research None None None None None None None Donald E. Casey, Jr. Atlantic Health Chief Medical Officer and Vice President of Quality None None None None None None None Mina K. Chung Cleveland Clinic Foundation Associate Professor of Medicine Biotronik Boston Scientific Nexcura PGx Sanofi-aventis St. Jude Medical None None Biotronik Boston Scientific GlaxoSmith Kline Medtronic Siemens Medical Solutions St. Jude Medical ZOLL Medtronic Boston Scientific St. Jude Medical None None James A. de Lemos UT Southwestern Medical School Professor of Medicine Johnson & Johnson Tethys AstraZeneca Daiichi-Sankyo BMS/ Sanofi- aventis None Bristol-Myers Squibb (DSMB) Roche Merck/Schering-Plough Daiichi-Sankyo None None 4.4.1 Steven M. Ettinger Penn State Heart & Vascular Institute Professor of Medicine and Radiology None None None Medtronic None None 4.3.1 James C. Fang University Hospitals Case Medical Center Director, Heart Transplantation Accorda Novartis Thoratec None None None Medtronic None 9.5.4.1 Francis M. Fesmire Heart Stroke Center Director Abbott None None None None Plaintiff, Missed Barry A. Franklin William Beaumont Hospital Director, Cardiac Rehabilitation and Exercise Laboratories None None None None None None None Christopher B. Granger Duke Clinical Research Institute Director, Cardiac Care Unit; Assistant Professor of Medicine AstraZeneca Boehringer Ingelheim Bristol-Myers Squibb GlaxoSmithKline Hoffman La Roche Novartis Sanofi-aventis The Medicines Company None None Astellas AstraZeneca Boehringer Ingelheim Bristol-Myers Squibb Eli Lilly GlaxoSmithKline Medtronic Merck Sanofi-aventis The Medicines Company None None 4.4.1 (Continued) Appendix 1.


Continued Committee Member Employment Consultant Speaker s Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Voting Recusals by Section* Harlan M. Krumholz Yale University School of Medicine Professor of Medicine United HealthCare (Science Advisory Group) None None None None None None Jane A. Linderbaum Mayo Clinic Assistant Professor of Medicine None None None None None None None David A. Morrow Harvard Medical School Associate Professor of Medicine Beckman-Coulter Boehringer Ingelheim Daiichi-Sankyo Eli Lilly Genentech Merck Novartis OrthoClinical Diagnostics/Johnson & Johnson Roche Diagnostics Sanofi-aventis Schering-Plough Research Institute Siemens Medical Solutions None None AstraZeneca Beckman-Coulter Daiichi-Sankyo Eli Lilly GlaxoSmithKline Merck Nanosphere Novartis Roche Diagnostics Sanofi-aventis Schering-Plough Research Institute Siemens Medical Solutions Singulex AstraZeneca None 3.2 L. Kristin Newby Duke University Medical Center, Division of Cardiology Professor of Medicine Amgen AstraZeneca BioVascular Johnson & Johnson Novartis None None BG Medicine Bristol-Myers Squibb diaDexus Eli Lilly GlaxoSmithKline Johnson & Johnson Merck Regado Schering-Plough None None 4.4.1 Joseph P. Ornato Department of Emergency Medicine Virginia Commonwealth University Professor and Chairman European Resuscitation Council ZOLL Circulation None None NIH/NINDS Neurological Emergency Treatment Trials Consortium PI None None None Narith Ou Mayo Clinic Pharmacotherapy Coordinator, Cardiology None None None None None None None Martha J. Radford NYU Langone Medical Center Chief Quality Officer; NYU School of Medicine Professor of Medicine (Cardiology) None None None None None None None Jacqueline E. Tamis-Holland St Luke s-Roosevelt Hospital Center Director, Interventional Cardiology Fellowship Program; Columbia University, College of Physicians and Surgeons Assistant Professor of Clinical Medicine None None None None None None None (Continued) O Gara et al 2013 ACCF/AHA STEMI Guideline e421 Appendix 1.


Continued Committee Member Employment Consultant Speaker s Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Voting Recusals by Section* Carl L. Tommaso Skokie Hospital Director of Catheterization Laboratory; North Shore University Health Systems None None None None None None None Cynthia M. Tracy George Washington University Medical Center Associate Director, Division of Cardiology None None None None None None None Y. Joseph Woo Hospital of the University of Pennsylvania Associate Professor of Surgery None None None None None None None David X. Zhao Vanderbilt University Medical Center Director, Cardiac Catheterization and Interventional Cardiology None None None Abbot Vascular Accumetrics AGA Medical Osiris Volcano None None 4.3.1 This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document. These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% of the voting stock or share of the business entity, or ownership of $10 000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person s gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted.


Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. According to the ACCF/AHA, a person has a relevant relationship IF: a) The relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) The company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) The person or a member of the person s household has a reasonable potential for financial, professional, or other personal gain or loss as a result of the issues/content addressed in the document. *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities could apply. No financial benefit. Significant relationship. Dr. Ettinger s relationship with Medtronic was added just before balloting of the recommendations, so it was not relevant during the writing stage; however, the addition of this relationship makes the writing committee out of compliance with the minimum 50% no relevant RWI requirement. ACS indicates acute coronary syndromes; DSMB, data safety monitoring board; NHLBI, National Heart, Lung, and Blood Institute; NIH, National Institutes of Health; and PI, principal investigator. Appendix 2.


ACS indicates acute coronary syndromes; DSMB, data safety monitoring board; NHLBI, National Heart, Lung, and Blood Institute; NIH, National Institutes of Health; and PI, principal investigator. Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant) 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction Reviewer Representation Consultant Speaker s Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Elliott M. Antman Official Reviewer ACCF Board of Trustees None None None Accumetrics AstraZeneca Beckman Coulter Bristol-Myers Squibb Pharmaceutical Research Institute Daiichi-Sankyo* Eli Lilly* GlaxoSmithKline Merck Millennium Pharmaceuticals Novartis Pharmaceuticals Ortho-Clinical Diagnostics Sanofi-Synthelabo Recherche Schering-Plough Research Institute None None Gary J. Balady Official Reviewer AHA None None None None None None Christopher P. Cannon Official Reviewer AHA Novartis None None Accumetrics* AstraZeneca* Bristol-Myers Squibb GlaxoSmithKline Merck* GlaxoSmithKline Merck (DSMB) None Judith S. Hochman Official Reviewer ACCF/AHA Task Force on Practice Guidelines BMS/Sanofi Eli Lilly GlaxoSmithKline None None None Johnson & Johnson Pharmaceutical Research & Development (DSMB) Merck/Schering Plough (DSMB) None Austin H. Kutscher Official Reviewer ACCF Board of Governors None None None None None None Charles J. Davidson Organizational Reviewer SCAI Abbott* Abbott Vascular None None Edwards Lifesciences* None None Deborah B. Diercks Organizational Reviewer ACEP Abbott Cardiovascular Daiichi-Sankyo None None Beckman Coulter Nanosphere None None Jonathan M. Tobis Organizational Reviewer SCAI None AGA Medical None AGA Medical* None None Boston Scientific Jeffrey L. Anderson Content Reviewer ACCF/AHA Task Force on Practice Guidelines None None None Toshiba AstraZeneca (DSMB) Defendant, Postoperative Ablation Case, James C. Blankenship Content Reviewer None None None AstraZeneca Boston Scientific Novartis Schering-Plough None None Jeffrey J. Cavendish Content Reviewer ACCF Prevention of Cardiovascular Disease Committee None None None None None None Harold L. Dauerman Content Reviewer None None None None None None John S. Douglas, Jr.


Reviewer Relationships With Industry and Other Entities (Relevant) 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction Reviewer Representation Consultant Speaker s Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Elliott M. Antman Official Reviewer ACCF Board of Trustees None None None Accumetrics AstraZeneca Beckman Coulter Bristol-Myers Squibb Pharmaceutical Research Institute Daiichi-Sankyo* Eli Lilly* GlaxoSmithKline Merck Millennium Pharmaceuticals Novartis Pharmaceuticals Ortho-Clinical Diagnostics Sanofi-Synthelabo Recherche Schering-Plough Research Institute None None Gary J. Balady Official Reviewer AHA None None None None None None Christopher P. Cannon Official Reviewer AHA Novartis None None Accumetrics* AstraZeneca* Bristol-Myers Squibb GlaxoSmithKline Merck* GlaxoSmithKline Merck (DSMB) None Judith S. Hochman Official Reviewer ACCF/AHA Task Force on Practice Guidelines BMS/Sanofi Eli Lilly GlaxoSmithKline None None None Johnson & Johnson Pharmaceutical Research & Development (DSMB) Merck/Schering Plough (DSMB) None Austin H. Kutscher Official Reviewer ACCF Board of Governors None None None None None None Charles J. Davidson Organizational Reviewer SCAI Abbott* Abbott Vascular None None Edwards Lifesciences* None None Deborah B. Diercks Organizational Reviewer ACEP Abbott Cardiovascular Daiichi-Sankyo None None Beckman Coulter Nanosphere None None Jonathan M. Tobis Organizational Reviewer SCAI None AGA Medical None AGA Medical* None None Boston Scientific Jeffrey L. Anderson Content Reviewer ACCF/AHA Task Force on Practice Guidelines None None None Toshiba AstraZeneca (DSMB) Defendant, Postoperative Ablation Case, James C. Blankenship Content Reviewer None None None AstraZeneca Boston Scientific Novartis Schering-Plough None None Jeffrey J. Cavendish Content Reviewer ACCF Prevention of Cardiovascular Disease Committee None None None None None None Harold L. Dauerman Content Reviewer None None None None None None John S. Douglas, Jr. Content Reviewer None None None Abbott Medtronic The Medicines Company None None Stephen G. Ellis Content Reviewer Abbott Vascular Boston Scientific None None None None None (Continued) O Gara et al 2013 ACCF/AHA STEMI Guideline e423 Appendix 2.


Content Reviewer None None None Abbott Medtronic The Medicines Company None None Stephen G. Ellis Content Reviewer Abbott Vascular Boston Scientific None None None None None (Continued) O Gara et al 2013 ACCF/AHA STEMI Guideline e423 Appendix 2. Continued Reviewer Representation Consultant Speaker s Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Joseph Fredi Content Reviewer ACCF Surgeons Scientific Council AGA Medical None None None None None Anthony Gershlick Content Reviewer Abbott AstraZeneca Boehringer Ingelheim Boston Scientific Cordis Eli Lilly Medtronic None None Boehringer Ingelheim None None Howard C. Herrmann Content Reviewer AstraZeneca Merck Sharpe and Dohme None None Accumetrics Boston Scientific* Edwards Lifesciences* eValve Medtronic* St. Jude Medical The Medicines Company* None None James Bernard Hermiller Content Reviewer ACCF Interventional Scientific Council Abbott Boston Scientific St. Jude Medical Eli Lilly None None None None Fred M. Kosumoto Content Reviewer None None None None None None Glenn Levine Content Reviewer None None None None None None Roxana Mehran Content Reviewer Abbott Vascular AstraZeneca Ortho-McNeill None None BMS/Sanofi-aventis* The Medicines Company* None None M. Eugene Sherman Content Reviewer ACCF Board of Governors None Eli Lilly* None None None None Daniel I. Simon Content Reviewer Cordis/Johnson & Johnson Daiichi-Sankyo Eli Lilly Medtronic Sanofi-aventis The Medicines Company None None None None Defendant, DES Intellectual Property Case, Richard W. Smalling Content Reviewer ACCF Interventional Scientific Council AGA Medical None None AGA Medical* Cordis* eValve* AGA Medical Cordis eValve None William G. Stevenson Content Reviewer ACCF/AHA Task Force on Practice Guidelines None None None None None None William A. Tansey III Content Reviewer None None None None None None David D. Waters Content Reviewer Bristol-Myers Squibb Pfizer None None None Merck/Schering-Plough Sanofi-aventis (DSMB) None Christopher J.


Continued Reviewer Representation Consultant Speaker s Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Joseph Fredi Content Reviewer ACCF Surgeons Scientific Council AGA Medical None None None None None Anthony Gershlick Content Reviewer Abbott AstraZeneca Boehringer Ingelheim Boston Scientific Cordis Eli Lilly Medtronic None None Boehringer Ingelheim None None Howard C. Herrmann Content Reviewer AstraZeneca Merck Sharpe and Dohme None None Accumetrics Boston Scientific* Edwards Lifesciences* eValve Medtronic* St. Jude Medical The Medicines Company* None None James Bernard Hermiller Content Reviewer ACCF Interventional Scientific Council Abbott Boston Scientific St. Jude Medical Eli Lilly None None None None Fred M. Kosumoto Content Reviewer None None None None None None Glenn Levine Content Reviewer None None None None None None Roxana Mehran Content Reviewer Abbott Vascular AstraZeneca Ortho-McNeill None None BMS/Sanofi-aventis* The Medicines Company* None None M. Eugene Sherman Content Reviewer ACCF Board of Governors None Eli Lilly* None None None None Daniel I. Simon Content Reviewer Cordis/Johnson & Johnson Daiichi-Sankyo Eli Lilly Medtronic Sanofi-aventis The Medicines Company None None None None Defendant, DES Intellectual Property Case, Richard W. Smalling Content Reviewer ACCF Interventional Scientific Council AGA Medical None None AGA Medical* Cordis* eValve* AGA Medical Cordis eValve None William G. Stevenson Content Reviewer ACCF/AHA Task Force on Practice Guidelines None None None None None None William A. Tansey III Content Reviewer None None None None None None David D. Waters Content Reviewer Bristol-Myers Squibb Pfizer None None None Merck/Schering-Plough Sanofi-aventis (DSMB) None Christopher J. White Content Reviewer None None None Boston Scientific St. Jude Medical None None (Continued) Appendix 2.


White Content Reviewer None None None Boston Scientific St. Jude Medical None None (Continued) Appendix 2. Continued Reviewer Representation Consultant Speaker s Bureau Ownership/ Partnership/ Principal Personal Research Institutional, Organizational, or Other Financial Benefit Expert Witness Clyde W. Yancy Content Reviewer ACCF/AHA Task Force on Practice Guidelines None None None None None None Yerem Yeghiazarians Content Reviewer None None None None None None This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review and determined to be relevant. It does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% of the voting stock or share of the business entity, or ownership of $10 000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person s gross income for the previous year. A relationship is considered to be modest if it is less than significant under the preceding definition. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. Names are listed in alphabetical order within each category of review.


Names are listed in alphabetical order within each category of review. According to the ACCF/AHA, a person has a relevant relationship IF: a) The relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) The company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) The person or a member of the person s household has a reasonable potential for financial, professional, or other personal gain or loss as a result of the issues/content addressed in the document. *Significant relationship. No financial benefit. ACCF indicates American College of Cardiology Foundation; ACEP, American College of Emergency Physicians; AHA, American Heart Association; DES, drug-eluting stent; DSMB, data safety monitoring board; and SCAI, Society for Cardiovascular Angiography and Interventions. O Gara et al 2013 ACCF/AHA STEMI Guideline e425 Appendix 3.


O Gara et al 2013 ACCF/AHA STEMI Guideline e425 Appendix 3. Abbreviation List ACE = angiotensin-converting enzyme ACS = acute coronary syndrome AF = atrial fibrillation ARB = angiotensin receptor blocker AV = atrioventricular BMS = bare-metal stent BP = blood pressure CABG = coronary artery bypass graft COX-2 = cyclooxygenase-II enzyme CPR = cardiopulmonary resuscitation CrCl = creatinine clearance D2B = door-to-balloon (device) DAPT = dual antiplatelet therapy DES = drug-eluting stent ECG = electrocardiogram/electrocardiographic ED = emergency department EF = ejection fraction EMS = emergency medical services FMC = first medical contact GP = glycoprotein HF = heart failure HIT = heparin-induced thrombocytopenia IABP = intra-aortic balloon counterpulsation ICD = implantable cardioverter-defibrillator ICH = intracranial hemorrhage LBBB = left bundle-branch block LDL = low-density lipoprotein LV = left ventricular LVEF = left ventricular ejection fraction MI = myocardial infarction NRMI = National Registry of Myocardial Infarction PCI = percutaneous coronary intervention RCT = randomized controlled trial RV = right ventricular SCD = sudden cardiac death STEMI = ST-elevation myocardial infarction TIMI = Thrombolysis In Myocardial Infarction UFH = unfractionated heparin VF = ventricular fibrillation VT = ventricular tachycardia


Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis Clinical guideline NICE 2022. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and- conditions#notice-of-rights). Last updated 30 November 2016 Your responsibility The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian. All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme. Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. Contents Overview 4 Who is it for?


Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. Contents Overview 4 Who is it for? 4 1.1 Providing information for people with chest pain 5 1.2 People presenting with acute chest pain 6 1.3 People presenting with stable chest pain 15 Terms used in this guideline 23 Recommendations for research 24 1 Cost-effectiveness of multislice CT coronary angiography for ruling out obstructive coronary artery disease in people with troponin-negative acute coronary syndromes 24 2 Refining the use of telephone advice in people with chest pain 24 3 Establishing a national registry for people who are undergoing initial assessment for stable 4 Information about presenting and explaining tests 26 Putting this guideline into practice 27 Finding more information and committee details 31 Update information 32 This guideline partially replaces TA73. This guideline is the basis of QS21 and QS68. This guideline should be read in conjunction with NG185. Overview This guideline covers assessing and diagnosing recent chest pain in people aged 18 and over and managing symptoms while a diagnosis is being made. It aims to improve outcomes by providing advice on tests (ECG, high-sensitivity troponin tests, multislice CT angiography, functional testing) that support healthcare professionals to make a speedy and accurate diagnosis. NICE has also produced a guideline on managing acute coronary syndromes. Who is it for? Healthcare professionals Adults with chest pain of recent onset, their families and carers Recommendations People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.


Healthcare professionals Adults with chest pain of recent onset, their families and carers Recommendations People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care. Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding. 1.1 Providing information for people with chest pain 1.1.1.1 Discuss any concerns people (and where appropriate their family or carer/advocate) may have, including anxiety when the cause of the chest pain is unknown. Correct any misinformation. [2010] 1.1.1.2 Offer people a clear explanation of the possible causes of their symptoms and the uncertainties. [2010] 1.1.1.3 Clearly explain the options to people at every stage of investigation. Make joint decisions with them and take account of their preferences: Encourage people to ask questions. Provide repeated opportunities for discussion. Explain test results and the need for any further investigations. [2010] 1.1.1.4 Provide information about any proposed investigations using everyday, jargon-free language. Include: their purpose, benefits and any limitations of their diagnostic accuracy duration level of discomfort and invasiveness risk of adverse events. [2010] 1.1.1.5 Offer information about the risks of diagnostic testing, including any radiation exposure. [2010] 1.1.1.6 Address any physical or learning difficulties, sight or hearing problems and difficulties with speaking or reading English, which may affect people's understanding of the information offered. [2010] 1.1.1.7 Offer information after diagnosis as recommended in the relevant disease management guidelines: NICE guideline on acute coronary syndromes NICE guideline on stable angina NICE guideline on generalised anxiety disorder and panic disorder in adults NICE guideline on gastro-oesophageal reflux disease and dyspepsia in adults.


[2010] 1.1.1.7 Offer information after diagnosis as recommended in the relevant disease management guidelines: NICE guideline on acute coronary syndromes NICE guideline on stable angina NICE guideline on generalised anxiety disorder and panic disorder in adults NICE guideline on gastro-oesophageal reflux disease and dyspepsia in adults. 1.1.1.8 Explain if the chest pain is non-cardiac and refer people for further investigation if appropriate. [2010] 1.1.1.9 Provide individual advice to people about seeking medical help if they have further chest pain. [2010] 1.2 People presenting with acute chest pain This section of the guideline covers the assessment and diagnosis of people with recent acute chest pain or discomfort, suspected to be caused by an acute coronary syndrome (ACS). The term ACS covers a range of conditions including unstable angina, ST-segment- elevation myocardial infarction (STEMI) and non-ST-segment-elevation myocardial infarction (NSTEMI). The guideline addresses assessment and diagnosis irrespective of setting, because people present in different ways. For early management of these conditions, follow the NICE guideline on acute coronary syndromes. 1.2.1 Initial assessment and referral to hospital 1.2.1.1 Check immediately whether people currently have chest pain. If they are pain free, check when their last episode of pain was, particularly if they have had pain in the last 12 hours. [2010] 1.2.1.2 Determine whether the chest pain may be cardiac and therefore whether this guideline is relevant, by considering: the history of the chest pain the presence of cardiovascular risk factors history of ischaemic heart disease and any previous treatment previous investigations for chest pain.


[2010] 1.2.1.2 Determine whether the chest pain may be cardiac and therefore whether this guideline is relevant, by considering: the history of the chest pain the presence of cardiovascular risk factors history of ischaemic heart disease and any previous treatment previous investigations for chest pain. [2010] 1.2.1.3 Initially assess people for any of the following symptoms, which may indicate an ACS: pain in the chest and/or other areas (for example, the arms, back or jaw) lasting longer than 15 minutes chest pain associated with nausea and vomiting, marked sweating, breathlessness, or particularly a combination of these chest pain associated with haemodynamic instability new onset chest pain, or abrupt deterioration in previously stable angina, with recurrent chest pain occurring frequently and with little or no exertion, and with episodes often lasting longer than 15 minutes. [2010] 1.2.1.4 Do not use people's response to glyceryl trinitrate (GTN) to make a 1.2.1.5 Do not assess symptoms of an ACS differently in men and women. Not all people with an ACS present with central chest pain as the predominant 1.2.1.6 Do not assess symptoms of an ACS differently in ethnic groups. There are no major differences in symptoms of an ACS among different ethnic 1.2.1.7 Refer people to hospital as an emergency if an ACS is suspected (see recommendation 1.2.1.3) and: they currently have chest pain or they are currently pain free, but had chest pain in the last 12 hours, and a resting 12-lead ECG is abnormal or not available.


There are no major differences in symptoms of an ACS among different ethnic 1.2.1.7 Refer people to hospital as an emergency if an ACS is suspected (see recommendation 1.2.1.3) and: they currently have chest pain or they are currently pain free, but had chest pain in the last 12 hours, and a resting 12-lead ECG is abnormal or not available. [2010] 1.2.1.8 If an ACS is suspected (see recommendation 1.2.1.3) and there are no reasons for emergency referral, refer people for urgent same-day assessment if: they had chest pain in the last 12 hours, but are now pain free with a normal resting 12-lead ECG or the last episode of pain was 12 to 72 hours ago. [2010] 1.2.1.9 Refer people for assessment in hospital if an ACS is suspected (see recommendation 1.2.1.3) and: the pain has resolved and there are signs of complications such as pulmonary oedema. Use clinical judgement to decide whether referral should be as an emergency or urgent same-day assessment. [2010] 1.2.1.10 If a recent ACS is suspected in people whose last episode of chest pain was more than 72 hours ago and who have no complications such as pulmonary oedema: carry out a detailed clinical assessment (see recommendations 1.2.4.2 and confirm the diagnosis by resting 12-lead ECG and blood troponin level take into account the length of time since the suspected ACS when interpreting the troponin level. Use clinical judgement to decide whether referral is necessary and how urgent this should be. [2010] 1.2.1.11 Refer people to hospital as an emergency if they have a recent (confirmed or suspected) ACS and develop further chest pain.


[2010] 1.2.1.11 Refer people to hospital as an emergency if they have a recent (confirmed or suspected) ACS and develop further chest pain. [2010] 1.2.1.12 When an ACS is suspected, start management immediately in the order appropriate to the circumstances (see the section on immediate management of a suspected acute coronary syndrome) and take a resting 12-lead ECG (see the section on resting 12-lead ECG). Take the ECG as soon as possible, but do not delay transfer to hospital. [2010] 1.2.1.13 If an ACS is not suspected, consider other causes of the chest pain, some of which may be life-threatening (see recommendations 1.2.6.5, 1.2.2.1 Take a resting 12-lead ECG as soon as possible. When people are referred, send the results to hospital before they arrive if possible. Recording and sending the ECG should not delay transfer to hospital. 1.2.2.2 Follow local protocols for people with a resting 12-lead ECG showing regional ST-segment elevation or presumed new left bundle branch block (LBBB) consistent with an acute STEMI until a firm diagnosis is made. Continue to monitor (see recommendation 1.2.3.4). [2010] 1.2.2.3 Follow the NICE guideline on acute coronary syndromes for people with a resting 12-lead ECG showing regional ST-segment depression or deep T wave inversion suggestive of a NSTEMI or unstable angina until a firm diagnosis is made. Continue to monitor (see recommendation 1.2.3.4). 1.2.2.4 Even in the absence of ST-segment changes, have an increased suspicion of an ACS if there are other changes in the resting 12-lead ECG, specifically Q waves and T wave changes. Consider following the NICE guideline on acute coronary syndromes if these conditions are likely. Continue to monitor (see recommendation 1.2.3.4). [2010] 1.2.2.5 Do not exclude an ACS when people have a normal resting 12-lead ECG.


[2010] 1.2.2.5 Do not exclude an ACS when people have a normal resting 12-lead ECG. 1.2.2.6 If a diagnosis of ACS is in doubt, consider: taking serial resting 12-lead ECGs reviewing previous resting 12-lead ECGs recording additional ECG leads. Use clinical judgement to decide how often this should be done. Note that the results may not be conclusive. [2010] 1.2.2.7 Obtain a review of resting 12-lead ECGs by a healthcare professional qualified to interpret them as well as taking into account automated 1.2.2.8 If clinical assessment (as described in recommendation 1.2.1.10) and a resting 12-lead ECG make a diagnosis of ACS less likely, consider other acute conditions. First consider those that are life-threatening such as pulmonary embolism, aortic dissection or pneumonia. Continue to monitor (see recommendation 1.2.3.4). [2010] 1.2.3 Immediate management of a suspected acute coronary syndrome Management of ACS should start as soon as it is suspected, but should not delay transfer to hospital. The recommendations in this section should be carried out in the order appropriate to the circumstances. 1.2.3.1 Offer pain relief as soon as possible. This may be achieved with GTN (sublingual or buccal), but offer intravenous opioids such as morphine, particularly if an acute myocardial infarction (MI) is suspected. [2010] 1.2.3.2 Offer people a single loading dose of 300 mg aspirin as soon as possible unless there is clear evidence that they are allergic to it. If aspirin is given before arrival at hospital, send a written record that it has been given with the person. Only offer other antiplatelet agents in hospital. Follow the NICE guideline on acute coronary syndromes. [2010] 1.2.3.3 Do not routinely administer oxygen, but monitor oxygen saturation using pulse oximetry as soon as possible, ideally before hospital admission.


[2010] 1.2.3.3 Do not routinely administer oxygen, but monitor oxygen saturation using pulse oximetry as soon as possible, ideally before hospital admission. Only offer supplemental oxygen to: people with oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94% to 98% people with chronic obstructive pulmonary disease who are at risk of hypercapnic respiratory failure, to achieve a target SpO2 of 88% to 92% until blood gas analysis is available. [2010] Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes. 1.2.3.4 Monitor people with acute chest pain, using clinical judgement to decide how often this should be done, until a firm diagnosis is made. This should include: exacerbations of pain and/or other symptoms pulse and blood pressure heart rhythm oxygen saturation by pulse oximetry repeated resting 12-lead ECGs and checking pain relief is effective. [2010] 1.2.3.5 Manage other therapeutic interventions using the NICE guideline on acute coronary syndromes. [2010] 1.2.4 Assessment in hospital for people with a suspected acute coronary syndrome 1.2.4.1 Take a resting 12-lead ECG and a blood sample for high-sensitivity troponin I or T measurement (see the section on use of biochemical markers for diagnosis of an acute coronary syndrome) on arrival in 1.2.4.2 Carry out a physical examination to determine: haemodynamic status signs of complications, for example, pulmonary oedema, cardiogenic shock and signs of non-coronary causes of acute chest pain, such as aortic dissection.


[2010] 1.2.4 Assessment in hospital for people with a suspected acute coronary syndrome 1.2.4.1 Take a resting 12-lead ECG and a blood sample for high-sensitivity troponin I or T measurement (see the section on use of biochemical markers for diagnosis of an acute coronary syndrome) on arrival in 1.2.4.2 Carry out a physical examination to determine: haemodynamic status signs of complications, for example, pulmonary oedema, cardiogenic shock and signs of non-coronary causes of acute chest pain, such as aortic dissection. 1.2.4.3 Take a detailed clinical history unless a STEMI is confirmed from the resting 12-lead ECG (that is, regional ST-segment elevation or presumed new LBBB). Record: the characteristics of the pain other associated symptoms any history of cardiovascular disease any cardiovascular risk factors and details of previous investigations or treatments for similar symptoms of chest 1.2.5 Use of biochemical markers for diagnosis of an acute coronary syndrome 1.2.5.1 Do not use high-sensitivity troponin tests for people in whom ACS is not 1.2.5.2 For people at high or moderate risk of MI (as indicated by a validated tool), perform high-sensitivity troponin tests as recommended in the NICE diagnostics guidance on myocardial infarction. [2016] 1.2.5.3 For people at low risk of MI (as indicated by a validated tool): perform a second high-sensitivity troponin test as recommended in the NICE diagnostics guidance on myocardial infarction if the first troponin test at presentation is positive. consider performing a single high-sensitivity troponin test only at presentation to rule out NSTEMI if the first troponin test is below the lower limit of detection 1.2.5.4 Ensure that patients understand that a detectable troponin on the first high-sensitivity test does not necessarily indicate that they have had an 1.2.5.5 Do not use biochemical markers such as natriuretic peptides and high- sensitivity C-reactive protein to diagnose an ACS.


consider performing a single high-sensitivity troponin test only at presentation to rule out NSTEMI if the first troponin test is below the lower limit of detection 1.2.5.4 Ensure that patients understand that a detectable troponin on the first high-sensitivity test does not necessarily indicate that they have had an 1.2.5.5 Do not use biochemical markers such as natriuretic peptides and high- sensitivity C-reactive protein to diagnose an ACS. [2010] 1.2.5.6 Do not use biochemical markers of myocardial ischaemia (such as ischaemia-modified albumin) as opposed to markers of necrosis when assessing people with acute chest pain. [2010] 1.2.5.7 When interpreting high-sensitivity troponin measurements, take into account: the clinical presentation the time from onset of symptoms the resting 12-lead ECG findings the pre-test probability of NSTEMI the length of time since the suspected ACS the probability of chronically elevated troponin levels in some people that 99th percentile thresholds for troponin I and T may differ between sexes. 1.2.6 Making a diagnosis 1.2.6.1 When diagnosing MI, use the universal definition of myocardial infarction. This is the detection of rise and/or fall of cardiac biomarkers values [preferably cardiac troponin (cTn)] with at least one value above the 99th percentile of the upper reference limit and at least one of the following: symptoms of ischaemia new or presumed new significant ST-segment-T wave (ST-T) changes or new LBBB development of pathological Q waves in the ECG imaging evidence of new loss of viable myocardium or new regional wall motion abnormality identification of an intracoronary thrombus by angiography. [2010, amended 1.2.6.2 When a raised troponin level is detected in people with a suspected ACS, reassess to exclude other causes for raised troponin (for example, myocarditis, aortic dissection or pulmonary embolism) before confirming the diagnosis of ACS.


[2010, amended 1.2.6.2 When a raised troponin level is detected in people with a suspected ACS, reassess to exclude other causes for raised troponin (for example, myocarditis, aortic dissection or pulmonary embolism) before confirming the diagnosis of ACS. [2010] 1.2.6.3 When a raised troponin level is detected in people with a suspected ACS, follow the NICE guideline on acute coronary syndromes until a firm diagnosis is made. Continue to monitor (see recommendation 1.2.3.4). 1.2.6.4 When a diagnosis of ACS is confirmed, follow the NICE guideline on acute coronary syndromes. [2010] 1.2.6.5 Reassess people with chest pain without raised troponin levels and no acute resting 12-lead ECG changes to determine whether their chest pain is likely to be cardiac. If myocardial ischaemia is suspected, follow the recommendations on stable chest pain in this guideline (see the section on people presenting with stable chest pain). Use clinical judgement to decide on the timing of any further diagnostic investigations. [2010, amended 2016] 1.2.6.6 Do not routinely offer non-invasive imaging or exercise ECG in the initial assessment of acute cardiac chest pain. [new 2016] 1.2.6.7 Only consider early chest computed tomography (CT) to rule out other diagnoses such as pulmonary embolism or aortic dissection, not to diagnose ACS. [2010] 1.2.6.8 Consider a chest X-ray to help exclude complications of ACS such as pulmonary oedema, or other diagnoses such as pneumothorax or 1.2.6.9 If an ACS has been excluded at any point in the care pathway, but people have risk factors for cardiovascular disease, follow the appropriate guidance, for example, the NICE guideline on cardiovascular disease and the NICE guideline on hypertension in adults. [2010] 1.3 People presenting with stable chest pain This section of the guideline addresses the assessment and diagnosis of intermittent stable chest pain in people with suspected stable angina.


[2010] 1.3 People presenting with stable chest pain This section of the guideline addresses the assessment and diagnosis of intermittent stable chest pain in people with suspected stable angina. 1.3.1.1 Exclude a diagnosis of stable angina if clinical assessment indicates non- anginal chest pain (see recommendation 1.3.3.1) and there are no other aspects of the history or risk factors raising clinical suspicion. [2016] 1.3.1.2 If clinical assessment indicates typical or atypical angina (see recommendation 1.3.3.1), offer diagnostic testing (see the sections on diagnostic testing for people in whom stable angina cannot be excluded by clinical assessment alone, additional diagnostic investigations and use of non-invasive functional testing for myocardial ischaemia). [2016] 1.3.2 Clinical assessment 1.3.2.1 Take a detailed clinical history documenting: the age and sex of the person the characteristics of the pain, including its location, radiation, severity, duration and frequency, and factors that provoke and relieve the pain any associated symptoms, such as breathlessness any history of angina, MI, coronary revascularisation or other cardiovascular disease and any cardiovascular risk factors. [2010] 1.3.2.2 Carry out a physical examination to: identify risk factors for cardiovascular disease identify signs of other cardiovascular disease identify non-coronary causes of angina (for example, severe aortic stenosis, cardiomyopathy) and exclude other causes of chest pain. [2010] 1.3.3 Making a diagnosis based on clinical assessment 1.3.3.1 Assess the typicality of chest pain as follows: Presence of three of the features below is defined as typical angina. Presence of two of the three features below is defined as atypical angina. Presence of one or none of the features below is defined as non-anginal chest pain. Anginal pain is: constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms precipitated by physical exertion relieved by rest or GTN within about 5 minutes.


Anginal pain is: constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms precipitated by physical exertion relieved by rest or GTN within about 5 minutes. [2010, amended 2016] 1.3.3.2 Do not define typical and atypical features of anginal chest pain and non- anginal chest pain differently in men and women. [2010] 1.3.3.3 Do not define typical and atypical features of anginal chest pain and non- anginal chest pain differently in ethnic groups. [2010] 1.3.3.4 Take the following factors, which make a diagnosis of stable angina more likely, into account when estimating people's likelihood of angina: age whether the person is male cardiovascular risk factors including: a history of smoking diabetes hypertension dyslipidaemia family history of premature coronary artery disease (CAD) other cardiovascular disease history of established CAD, for example, previous MI, coronary 1.3.3.5 Unless clinical suspicion is raised based on other aspects of the history and risk factors, exclude a diagnosis of stable angina if the pain is non- anginal (see recommendation 1.3.3.1). Features which make a diagnosis of stable angina unlikely are when the chest pain is: continuous or very prolonged and/or unrelated to activity and/or brought on by breathing in and/or associated with symptoms such as dizziness, palpitations, tingling or difficulty swallowing. Consider causes of chest pain other than angina (such as gastrointestinal or musculoskeletal pain). [2010] 1.3.3.6 Consider investigating other causes of angina, such as hypertrophic cardiomyopathy, in people with typical angina-like chest pain and a low likelihood of CAD. [2010, amended 2016] 1.3.3.7 Arrange blood tests to identify conditions which exacerbate angina, such as anaemia, for all people being investigated for stable angina.


[2010, amended 2016] 1.3.3.7 Arrange blood tests to identify conditions which exacerbate angina, such as anaemia, for all people being investigated for stable angina. [2010] 1.3.3.8 Only consider chest X-ray if other diagnoses, such as a lung tumour, are 1.3.3.9 If a diagnosis of stable angina has been excluded at any point in the care pathway, but people have risk factors for cardiovascular disease, follow the appropriate guidance, for example, the NICE guideline on cardiovascular disease and the NICE guideline on hypertension in adults. 1.3.3.10 For people in whom stable angina cannot be excluded on the basis of the clinical assessment alone, take a resting 12-lead ECG as soon as possible after presentation. [2010, amended 2016] 1.3.3.11 Do not rule out a diagnosis of stable angina on the basis of a normal 1.3.3.12 Do not offer diagnostic testing to people with non-anginal chest pain on clinical assessment (see recommendation 1.3.3.1) unless there are resting ECG ST-T changes or Q waves. [2016] 1.3.3.13 A number of changes on a resting 12-lead ECG are consistent with CAD and may indicate ischaemia or previous infarction. These include: pathological Q waves in particular LBBB ST-segment and T wave abnormalities (for example, flattening or inversion). Note that the results may not be conclusive. Consider any resting 12-lead ECG changes together with people's clinical history and risk factors. [2010] 1.3.3.14 For people with confirmed CAD (for example, previous MI, revascularisation, previous angiography) in whom stable angina cannot be excluded based on clinical assessment alone, see recommendation 1.3.3.15 Consider aspirin only if the person's chest pain is likely to be stable angina, until a diagnosis is made. Do not offer additional aspirin if there is clear evidence that people are already taking aspirin regularly or are allergic to it.


Do not offer additional aspirin if there is clear evidence that people are already taking aspirin regularly or are allergic to it. [2010] 1.3.3.16 Follow the NICE guideline on stable angina while waiting for the results of investigations if symptoms are typical of stable angina. [2010] 1.3.4 Diagnostic testing for people in whom stable angina cannot be excluded by clinical assessment alone The Guideline Development Group emphasised that the recommendations in this guideline are to make a diagnosis of chest pain, not to screen for CAD. Most people diagnosed with non-anginal chest pain after clinical assessment need no further diagnostic testing. However in a very small number of people, there are remaining concerns that the pain could be ischaemic. 1.3.4.1 Include the typicality of anginal pain features (see recommendation 1.3.3.1) in all requests for diagnostic investigations and in the person's 1.3.4.2 Use clinical judgement and take into account people's preferences and comorbidities when considering diagnostic testing. [2010] 1.3.4.3 Offer 64-slice (or above) CT coronary angiography if: clinical assessment (see recommendation 1.3.3.1) indicates typical or atypical angina or clinical assessment indicates non-anginal chest pain but 12-lead resting ECG has been done and indicates ST-T changes or Q waves. [2016] 1.3.4.4 For people with confirmed CAD (for example, previous MI, revascularisation, previous angiography), offer non-invasive functional testing when there is uncertainty about whether chest pain is caused by myocardial ischaemia. See the section on use of non-invasive functional testing for myocardial ischaemia for further guidance on non-invasive functional testing. An exercise ECG may be used instead of functional See also NICE's medical technologies guidance on HeartFlow FFRCT for estimating fractional flow reserve from coronary CT angiography.


An exercise ECG may be used instead of functional See also NICE's medical technologies guidance on HeartFlow FFRCT for estimating fractional flow reserve from coronary CT angiography. Using HeartFlow FFRCT may avoid the need for invasive coronary angiography and revascularisation for some patients 1.3.5 Additional diagnostic investigations 1.3.5.1 Offer non-invasive functional imaging (see the section on use of non- invasive functional testing for myocardial ischaemia) for myocardial ischaemia if 64-slice (or above) CT coronary angiography has shown CAD of uncertain functional significance or is non-diagnostic. [2016] 1.3.5.2 Offer invasive coronary angiography as a third-line investigation when the results of non-invasive functional imaging are inconclusive. [2016] 1.3.6 Use of non-invasive functional testing for myocardial ischaemia 1.3.6.1 When offering non-invasive functional imaging for myocardial ischaemia use: myocardial perfusion scintigraphy with single photon emission computed tomography (MPS with SPECT) or stress echocardiography or first-pass contrast-enhanced magnetic resonance (MR) perfusion or MR imaging for stress-induced wall motion abnormalities. Take account of locally available technology and expertise, the person and their preferences, and any contraindications (for example, disabilities, frailty, limited ability to exercise) when deciding on the imaging method. [This recommendation updates and replaces recommendation 1.1 of NICE's technology appraisal guidance on myocardial perfusion scintigraphy for the diagnosis and management of angina and myocardial infarction]. [2016] 1.3.6.2 Use adenosine, dipyridamole or dobutamine as stress agents for MPS with SPECT and adenosine or dipyridamole for first-pass contrast- enhanced MR perfusion. [2010] 1.3.6.3 Use exercise or dobutamine for stress echocardiography or MR imaging for stress-induced wall motion abnormalities. [2010] 1.3.6.4 Do not use MR coronary angiography for diagnosing stable angina. 1.3.6.5 Do not use exercise ECG to diagnose or exclude stable angina for people without known CAD.


1.3.6.5 Do not use exercise ECG to diagnose or exclude stable angina for people without known CAD. [2010] 1.3.7 Making a diagnosis following investigations Box 1 Definition of significant coronary artery disease Significant coronary artery disease (CAD) found during CT coronary angiography is 70% diameter stenosis of at least one major epicardial artery segment or 50% diameter stenosis in the left main coronary artery: Factors intensifying ischaemia Such factors allow less severe lesions (for example, 50%) to produce angina: reduced oxygen delivery: anaemia, coronary spasm increased oxygen demand: tachycardia, left ventricular hypertrophy large mass of ischaemic myocardium: proximally located lesions longer lesion length. Factors reducing ischaemia which may render severe lesions ( 70%) asymptomatic: Well-developed collateral supply. Small mass of ischaemic myocardium: distally located lesions, old infarction in the territory of coronary supply. [2016] 1.3.7.1 Confirm a diagnosis of stable angina and follow the NICE guideline on stable angina when: significant CAD (see box 1) is found during invasive or 64-slice (or above) CT coronary angiography or reversible myocardial ischaemia is found during non-invasive functional 1.3.7.2 Investigate other causes of chest pain when: significant CAD (see box 1) is not found during invasive coronary angiography or 64-slice (or above) CT coronary angiography or reversible myocardial ischaemia is not found during non-invasive functional 1.3.7.3 Consider investigating other causes of angina, such as hypertrophic cardiomyopathy or syndrome X, in people with typical angina-like chest pain if investigation excludes flow-limiting disease in the epicardial coronary arteries. [2010] Terms used in this guideline Chest pain The term 'chest pain' is used throughout the guideline to mean chest pain or discomfort. Recommendations for research In 2010, the guideline committee made the following recommendations for research. The committee's full set of recommendations for research is detailed in the full guideline.


The committee's full set of recommendations for research is detailed in the full guideline. 1 Cost-effectiveness of multislice CT coronary angiography for ruling out obstructive coronary artery disease in people with troponin-negative acute coronary syndromes Is multislice CT coronary angiography a cost-effective first-line test for ruling out obstructive coronary artery disease (CAD) in people with suspected troponin-negative acute coronary syndromes? Why this is important Current European Society of Cardiology guidelines state that in troponin-negative ACS with no ST-segment change on the ECG, 'a stress test is recommended in patients with significant ischaemia during the stress test, coronary angiography and subsequent revascularisation should be considered'. Yet stress testing has relatively low sensitivity and specificity for diagnosing CAD in this group of people. Therefore a significant proportion of at-risk people are missed while others with normal coronary arteries are subjected to an unnecessary invasive coronary angiogram. Multislice CT coronary angiography is highly sensitive and provides a potentially useful means for early rule-out of CAD in troponin- negative acute coronary disease. We need to know whether it is cost effective compared with exercise ECG as a first test in the diagnostic work-up of this group. 2 Refining the use of telephone advice in people with chest pain In what circumstances should telephone advice be given to people calling with chest pain? Is the appropriateness influenced by age, sex or symptoms? Why this is important The telephone is a common method of first contact with healthcare services, and produces a near uniform emergency response to chest pain symptoms. Such a response has considerable economic, social and human costs.


Such a response has considerable economic, social and human costs. Research should be conducted to clarify if an emergency response in all circumstances is appropriate, or if there are identifiable factors such as age, sex or associated symptoms that would allow a modified response and a more appropriate use of resources. 3 Establishing a national registry for people who are undergoing initial assessment for stable angina Can a national registry of people presenting with suspected angina be established to allow cohort analysis of treatments, investigations and outcomes in this group? Such a registry would provide a vital resource for a range of important research projects, including: development and validation of a new score for assessing the pre-test probability of disease, addressing outstanding uncertainties in the estimation of the pre-test probability of CAD based on simple measures made at initial assessment (history, examination, routine bloods, resting 12-lead ECG) assessment of the extent to which new circulating biomarkers add additional information to measures made at initial assessment provision of a framework for trial recruitment without significant work-up bias allowing evaluation of the diagnostic and prognostic test performance of CT-based, MR, echocardiography and radionuclide technologies. Why this is important A national prospective registry of consecutive people with suspected stable angina before initial diagnostic testing does not currently exist in the UK or in any other country. Establishing such a registry would offer the following methodological strengths: statistical size, representative patients without work-up bias, contemporary data. This would overcome key problems in much of the existing evidence base. Accurate assessment of pre-test likelihood of coronary disease is needed to inform the cost-effective choice of investigative technologies such as CT coronary calcium scoring for people with chest pain that may be caused by myocardial ischaemia.


Accurate assessment of pre-test likelihood of coronary disease is needed to inform the cost-effective choice of investigative technologies such as CT coronary calcium scoring for people with chest pain that may be caused by myocardial ischaemia. The data on which pre-test likelihood is based date from 1979 in a US population and may not be applicable to contemporary UK populations. There remain continuing uncertainties about the initial assessment of people with suspected stable angina. For example, the possible contributions of simple clinical measures such as body mass index, routine blood markers (for example, haemoglobin) or novel circulating biomarkers to estimates of the pre-test likelihood of CAD are not known and require further assessment in the whole population and in predefined subgroups including ethnic minorities. 4 Information about presenting and explaining tests All people presenting with chest pain will need to decide whether to accept the diagnostic and care pathways offered. How should information about the diagnostic pathway and the likely outcomes, risks and benefits, with and without treatment, be most effectively presented to particular groups of people, defined by age, ethnicity and sex? Why this is important Methods of communication (both the content and delivery) will be guided by current evidence-based best practice. Controlled trials should be conducted based on well- constructed randomised controlled clinical trials comparing the effects of different methods of communication on the understanding of the person with chest pain. Such studies might consider a number of delivery mechanisms, including advice and discussion with a clinician or a specialist nurse, as well as specific information leaflets or visual data. Any trials should also investigate the feasibility of introducing a suggested guideline protocol to be used with all people presenting with chest pain when faced with options concerning their clinical pathway.


Any trials should also investigate the feasibility of introducing a suggested guideline protocol to be used with all people presenting with chest pain when faced with options concerning their clinical pathway. Only by clearly explaining and then discussing the proposed diagnostic and care pathways can the healthcare professional be reasonably certain that informed consent has been obtained and that a patient's moral, ethical and spiritual beliefs, expectations, and any misconceptions about their condition, have been taken into account. Consideration should be given to any communication problems the person may have. Putting this guideline into practice NICE has produced tools and resources to help you put this guideline into practice. Putting recommendations into practice can take time. How long may vary from guideline to guideline, and depends on how much change in practice or services is needed. Implementing change is most effective when aligned with local priorities. Changes recommended for clinical practice that can be done quickly like changes in prescribing practice should be shared quickly. This is because healthcare professionals should use guidelines to guide their work as is required by professional regulating bodies such as the General Medical and Nursing and Midwifery Councils. Changes should be implemented as soon as possible, unless there is a good reason for not doing so (for example, if it would be better value for money if a package of recommendations were all implemented at once). Different organisations may need different approaches to implementation, depending on their size and function. Sometimes individual practitioners may be able to respond to recommendations to improve their practice more quickly than large organisations. Here are some pointers to help organisations put NICE guidelines into practice: 1.


Here are some pointers to help organisations put NICE guidelines into practice: 1. Raise awareness through routine communication channels, such as email or newsletters, regular meetings, internal staff briefings and other communications with all relevant partner organisations. Identify things staff can include in their own practice straight away. 2. Identify a lead with an interest in the topic to champion the guideline and motivate others to support its use and make service changes, and to find out any significant issues locally. 3. Carry out a baseline assessment against the recommendations to find out whether there are gaps in current service provision. 4. Think about what data you need to measure improvement and plan how you will collect it. You may want to work with other health and social care organisations and specialist groups to compare current practice with the recommendations. This may also help identify local issues that will slow or prevent implementation. 5. Develop an action plan, with the steps needed to put the guideline into practice, and make sure it is ready as soon as possible. Big, complex changes may take longer to implement, but some may be quick and easy to do. An action plan will help in both cases. 6. For very big changes include milestones and a business case, which will set out additional costs, savings and possible areas for disinvestment. A small project group could develop the action plan. The group might include the guideline champion, a senior organisational sponsor, staff involved in the associated services, finance and information professionals. 7. Implement the action plan with oversight from the lead and the project group. Big projects may also need project management support. 8. Review and monitor how well the guideline is being implemented through the project group.


8. Review and monitor how well the guideline is being implemented through the project group. Share progress with those involved in making improvements, as well as relevant boards and local partners. NICE provides a comprehensive programme of support and resources to maximise uptake and use of evidence and guidance. See our into practice pages for more information. Also see Leng G, Moore V, Abraham S, editors (2014) Achieving high quality care practical experience from NICE. Chichester: Wiley. Context Conditions causing chest pain or discomfort, such as an acute coronary syndrome or angina, have a potentially poor prognosis, emphasising the importance of prompt and accurate diagnosis. Treatments are available to improve symptoms and prolong life, hence the need for this guideline. This guideline covers the assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. In deciding whether chest pain may be cardiac and therefore whether this guideline is relevant, a number of factors should be taken into account. These include the person's history of chest pain, their cardiovascular risk factors, history of ischaemic heart disease and any previous treatment, and previous investigations for chest pain. For pain that is suspected to be cardiac, there are two separate diagnostic pathways presented in the guideline. The first is for people with acute chest pain and a suspected acute coronary syndrome, and the second is for people with intermittent stable chest pain in whom stable angina is suspected. The guideline includes how to determine whether myocardial ischaemia is the cause of the chest pain and how to manage the chest pain while people are being assessed and investigated. As far as possible, the recommendations in this guideline have been listed in the order in which they will be carried out and follow the diagnostic pathways.


As far as possible, the recommendations in this guideline have been listed in the order in which they will be carried out and follow the diagnostic pathways. But, as there are many permutations at each decision point, it has been necessary to include frequent cross- referencing to avoid repeating recommendations several times. The algorithms presented in full guideline show the two diagnostic pathways. This guideline does not cover the diagnosis and management of chest pain that is unrelated to the heart (for example, traumatic chest wall injury, herpes zoster infection) when myocardial ischaemia has been excluded. The guideline also recognises that in people with a prior diagnosis of coronary artery disease, chest pain or discomfort is not necessarily cardiac. The term 'chest pain' is used throughout the guideline to mean chest pain or discomfort. The guideline will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients. Finding more information and committee details To find NICE guidance on related topics, including guidance in development, see the NICE topic page on cardiovascular conditions. For full details of the evidence and the guideline committee's discussions, see the full guideline. You can also find information about how this guideline was developed, including details of the committee. NICE has produced tools and resources to help you put this guideline into practice. For general help and advice on putting our guidelines into practice, see resources to help you put NICE guidance into practice. Update information November 2016: New recommendations have been added for the assessment and diagnosis of acute chest pain and the assessment and diagnosis of stable chest pain. These are marked as [2016]. Where recommendations end [2010], the evidence has not been reviewed since the original guideline.


Where recommendations end [2010], the evidence has not been reviewed since the original guideline. We have also made some changes without an evidence review: some 2010 recommendations have been updated to align with the 2016 recommendations some recommendations have been updated to clarify the use of high-sensitivity troponin testing some recommendations have been updated to remove reference to estimate of the likelihood of coronary artery disease reference to autopsy as a diagnostic criterion has been removed. These recommendations are marked [2010, amended 2016]. Minor changes since publication October 2022: We added text to indicate that pulse oximetry may be less reliable in people with dark skin. We also added a link to the NHS patient safety alert on the risk of harm from inappropriate placement of pulse oximeter probes. See recommendation 1.2.3.3. November 2020: We linked to the updated guideline on acute coronary syndromes. August2020: We linked to updated diagnostics guidance in recommendations on use of biochemical markers for diagnosis (section 1.2.5). January 2020: The title of the guideline was updated to clarify that it covers chest pain of suspected cardiac origin. We linked to the universal definition of myocardial infarction in recommendation 1.2.6.1 and added a cross-reference to related NICE medical technologies guidance at the end of section 1.3.4. Accreditation


Hypertension in pregnancy: diagnosis and management NICE guideline NICE 2023. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and- conditions#notice-of-rights). Last updated 17 April 2023 Your responsibility The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian. All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme. Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. Contents Overview 5 Who is it for?


Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. Contents Overview 5 Who is it for? 5 1.1 Reducing the risk of hypertensive disorders in pregnancy 6 1.2 Assessment of proteinuria in hypertensive disorders of pregnancy 8 1.3 Management of chronic hypertension in pregnancy 10 1.4 Management of gestational hypertension 14 1.5 Management of pre-eclampsia 18 1.7 Intrapartum care 28 1.8 Medical management of severe hypertension, severe pre-eclampsia or eclampsia in a critical care setting 30 1.9 Antihypertensive treatment during the postnatal period, including during breastfeeding 33 1.10 Advice and follow-up at transfer to community care 35 Terms used in this guideline 39 Recommendations for research 42 Key recommendations for research 42 Other recommendations for research (from 2010 guideline) 43 Rationale and impact 44 Assessment of proteinuria 44 Treatment of chronic hypertension 46 Monitoring and treatment of gestational hypertension 48 Assessment of women with pre-eclampsia 49 Monitoring and treatment of pre-eclampsia and timing of birth 50 Antihypertensive treatment during the postnatal period, including during breastfeeding 52 Risk of recurrence of hypertensive disorders of pregnancy and long-term cardiovascular disease 53 Finding more information and committee details 56 Update information 57 This guideline replaces CG107. This guideline is the basis of QS35. Overview This guideline covers diagnosing and managing hypertension (high blood pressure), including pre-eclampsia, during pregnancy, labour and birth. It also includes advice for women with hypertension who wish to conceive and women who have had a pregnancy complicated by hypertension. It aims to improve care during pregnancy, labour and birth for women and their babies. We've created a series of visual summaries to explain assessment, treatment and other aspects of care for various conditions relating to hypertension in pregnancy.


We've created a series of visual summaries to explain assessment, treatment and other aspects of care for various conditions relating to hypertension in pregnancy. These are available to download from tools and resources. Who is it for? Healthcare professionals Women who develop hypertension during pregnancy, who have hypertension and wish to conceive, and who have had a pregnancy complicated by hypertension, and their relatives and carers Recommendations People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care. Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding. 1.1 Reducing the risk of hypertensive disorders in pregnancy Symptoms of pre-eclampsia 1.1.1 Advise pregnant women to see a healthcare professional immediately if they experience symptoms of pre-eclampsia. Symptoms include: severe headache problems with vision, such as blurring or flashing before the eyes severe pain just below the ribs vomiting sudden swelling of the face, hands or feet. See the NICE guideline on antenatal care for advice on risk factors and symptoms of pre-eclampsia. [2010, amended 2019] Antiplatelet agents 1.1.2 Advise pregnant women at high risk of pre-eclampsia to take 75 150 mg of aspirin daily from 12 weeks until the birth of the baby. Women at high risk are those with any of the following: hypertensive disease during a previous pregnancy chronic kidney disease autoimmune disease such as systemic lupus erythematosus or antiphospholipid syndrome type 1 or type 2 diabetes chronic hypertension.