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Diagnostic coronary angiography for low risk, stable chest pain

Diagnostic coronary angiography for low risk, stable chest pain

Best Practice Guidance

How up to date is this information?

Published January 2020 | Last reviewed September 2024

Using this guidance

The guidance set out here was reviewed extensively in the Autumn of 2024. There are no plans for any further reviews.

Medicine is constantly evolving and over time it is inevitable that the evidence base will change. Please use your own judgement and/or other sources of clinical guidance alongside the information set out here.

Please note this guidance is a recommendation and it should be used in the context of the overall care pathway and when all alternative interventions that may be available locally have been undertaken.

Summary

NICE guidelines recommend that where a diagnosis of chest pain cannot, by clinical assessment alone, exclude stable angina, 64-slice (or above) CT coronary angiography should be offered as first-line. Invasive coronary angiography should only be offered to patients with significant findings on CT coronary angiogram or with inconclusive further imaging.

This guidance applies to adults aged 19 years and over.

Recommendation

When results of non-invasive functional imaging are inconclusive and patients are assessed as having low risk, stable cardiac pain, invasive coronary angiography (cardiac catheterisation) should be offered only as third-line investigation.

Patients who have chest pain that is not an Acute Coronary Syndrome (ACS), but there is concern that it is due to an ischemic cause (stable angina) should, in the first instance, be offered a CT Coronary angiography (64 slice or above). This is based on:

  • Clinical assessment indicating typical or atypical angina; or
  • Clinical assessment indicates non-anginal chest pain but the 12‑lead resting ECG shows ST‑T changes or Q waves.

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.

If the CT coronary angiography is inconclusive, non-invasive functional imaging for myocardial ischemia should be considered in the following forms:

  • Stress echocardiography; or
  • First-pass contrast-enhanced magnetic resonance (MR) stress perfusion; or
  • MR imaging for stress-induced wall motion abnormalities; or
  • Fractional flow reserve CT (FFR-CT); or
  • Myocardial perfusion scintigraphy with single photon emission computed tomography (MPS with SPECT).

Invasive coronary angiography should only be offered as third-line investigation when the results of non-invasive functional imaging are inconclusive.

Rationale for recommendation

NICE guidelines recommend that where a diagnosis of chest pain cannot, by clinical assessment alone, exclude stable angina, 64-slice (or above) CT coronary angiography should be offered as first-line investigation. Cardiac catheterisation and coronary angiography are generally considered to be safe procedures. However, as with all medical procedures, there are some associated risks. The main risks of coronary angiography include:

  • Haematoma or bruising in groin or arm
  • Allergy to the contrast
  • A very small risk including damage to the artery in the arm or leg where the catheter was inserted, heart attack, stroke, kidney damage and, very rarely, death (risk of a serious complication occurring is estimated to be less than 1 in 1,000. People with serious underlying heart problems are most at risk.)

Patient information

There is no specific EBI patient guidance for this intervention.

However, we recommend using the BRAN principles (Benfits, Risks, Alternatives and do Nothing) when speaking with patients about this.

Further information on patient involvement in EBI can be found on the EBI for patients section.

Make the most of your appointment using BRAN

2020

Coding

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AND NOT ( Any_Spell_Diagnosis LIKE '%I20[018]%' 
OR Any_Spell_Diagnosis LIKE '%I21[012349]%'
OR Any_Spell_Diagnosis LIKE '%I2[24][0189]%'
OR Any_Spell_Diagnosis LIKE '%I23[01234568]%'
OR Any_Spell_Diagnosis LIKE '%I25[012345689]%')
AND NOT ( Any_Spell_Procedure LIKE '%U10[1-9]%'
OR Any_Spell_Procedure LIKE '%U205%'
OR Any_Spell_Procedure LIKE '%U115%')
-- Age between 19 and 120
AND ISNULL(APCS.Age_At_Start_of_Spell_SUS,APCS.Der_Age_at_CDS_Activity_Date) between 19 AND 120 
THEN '2A_Angio'
Exclusions
 WHERE 1=1
-- Cancer Diagnosis Exclusion
AND (Any_Spell_Diagnosis not like '%C[0-9][0-9]%' 
AND Any_Spell_Diagnosis not like '%D0%' 
AND Any_Spell_Diagnosis not like '%D3[789]%' 
AND Any_Spell_Diagnosis not like '%D4[012345678]%' 
OR Any_Spell_Diagnosis IS NULL)
-- Private Appointment Exclusion
AND apcs.Administrative_Category<>'02'

References

  1. Clinical guidance (2010) Chest pain of recent onset: assessment and diagnosis (clinical guideline [CG95]
  2. NICE Resource (2016) Resource impact report: Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis (CG95)
  3. NHS advice: https://www.nhs.uk/conditions/coronary-angiography/
  4. NHS advice: https://www.nhs.uk/conditions/coronary-angiography/risks/
  5. NICE. Medical technologies guidance (2017) HeartFlow FFRCT for estimating fractional flow reserve from coronary CT angiography [MTG32].
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