In November 2016, the United Kingdom’s National Institute for Health and Care Excellence (NICE) provided an update to its widely recognized chest pain document, which included the use of coronary CT angiography (CCTA) in the diagnosis of stable chest pain. Specifically, the writing group acknowledged the utility of CCTA in patients with either 1) typical or atypical angina, or 2) those with non-anginal chest pain but an equivocal ECG (nonspecific ST-T wave changes or Q waves), if a 64-slice MDCT or higher detector row scanner was available. A great deal of flexibility is included in the NICE approach, which encourages clinicians to use both judgment and interaction with the patient in the ultimate choice of non-invasive imaging modality.
Of note, for those patients with known coronary disease, functional testing is recommended. The definition of functional testing was also expanded in the 2016 update to include: SPECT-MPI, stress echocardiography, first pass contrast-enhanced MR perfusion and MR imaging for stress induced wall motion abnormalities. CCTA was not recommended in the NICE guidelines for patients with suspected acute coronary syndrome, unless a CT was indicated for pulmonary embolism or aortic dissection.
The NICE chest pain document, in general, echoes the recommendations also put forth in the joint ACR/ACC statement for the appropriate utilization of cardiovascular imaging in emergency department patients with chest pain, published in February 2016. CCTA has become a much more prominent and accepted modality for the evaluation of the spectrum of stable chest pain, excluding confirmed acute coronary syndromes, with additional benefits of providing information in unclear clinical scenarios in which pulmonary embolism and acute syndromes of the aorta are also being considered.
The NICE guidelines reflect the successful early adoption of an evidence-based application of cardiac CT into routine clinical practice in the UK. Through your continued support and input, we as a society can continue to educate and advocate for the appropriate use of cardiac CT in the evaluation of chest pain.
For more information on the NICE guidelines: NICE Chest Pain Clinical Guidelines, Updated 2016
- Jeannie H. Yu, MD, FSCCT
SCCT Advocacy Committee