Unstable angina and NSTEMI: early management - NICE guideline

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This guideline covers treatments for people aged 18 and over with unstable angina (recurring chest pain) or a type of heart attack called non-ST-segment-elevation myocardial infarction (NSTEMI). It aims to ensure that people get treatment quickly. It recommends that as soon as NSTEMI or unstable angina is diagnosed, healthcare professionals assess people for risk of more serious heart problems in the future to guide their treatment. 

Key recommendations

Testing for ischaemia

What is the role of ischaemia testing in people after an acute coronary syndrome and what is the comparative efficacy and cost effectiveness of the different non-invasive tests (for example, stress ECG, echocardiography, radionuclide scanning and magnetic resonance imaging)?

Why this is important

An increasing number of non-invasive tests are now available for the investigation of suspected myocardial ischaemia. These tests need different equipment, different clinical expertise, come at different costs and may differ in their ability to detect and quantify myocardial ischaemia. Their place in the routine investigation of patients admitted with unstable angina and NSTEMI (particularly those who have not undergone angiography), as opposed to their selective use, is not clear. Management of unstable angina and NSTEMI would be enhanced if the relative place of these investigations was better understood and an assessment of their cost effectiveness made.

Risk assessment

What is the clinical and cost effectiveness of the systematic use of risk scoring systems (in addition to clinical assessment) for ischaemic outcomes and bleeding complications in the management of unstable angina and NSTEMI (at all levels of risk) compared with clinical assessment alone?

Why this is important

Most risk scoring systems currently predict the likelihood of mortality or ischaemic cardiovascular events at various times after a patient's admission to hospital with an acute coronary syndrome. A number of interventions (such as drugs and revascularisation procedures) have been shown to reduce these adverse outcomes. This effect tends to be greatest in patients at highest risk. However, as a broad generalisation patients who are at highest ischaemic risk are also those who are at higher risk of bleeding complications associated with the use of multiple antiplatelet and antithrombin agents. There are fewer scoring systems that predict bleeding risk, but we know that bleeding complications are associated with a significantly worse outcome. Using a combination of scoring systems assessing ischaemic and bleeding risk when evaluating data from randomised trials and registries may help to determine where the net clinical benefit (reduction in ischaemic risk minus any increase in bleeding risk) lies.

For patients with unstable angina and NSTEMI (at differing levels of risk), how do clinical outcome data (adverse cardiovascular events and bleeding complications) collected in cardiac registries compare with data derived from randomised clinical trials (RCTs).

Why this is important

Patients recruited to participate in clinical trials are often highly selected; trials tend not to include patients who are very elderly, are at high risk, or have significant comorbidity. On the other hand, good registry data include information on all patients, but are observational and not randomised. Often there is uncertainty about how the outcome data from RCTs can be applied to the much larger unselected population of patients admitted to UK hospitals with unstable angina or NSTEMI. A greater understanding of the differences between RCT and registry populations, and their levels of ischaemic and bleeding risk would help inform future management. Collection of well-validated registry data is essential if conclusions from RCTs are to be applied appropriately to all patients with unstable angina and NSTEMI, not just to patients who are comparable to trial populations.

What is angina and NSTEMI?

The term 'acute coronary syndromes' encompasses a range of conditions from unstable angina to ST-segment-elevation myocardial infarction (STEMI), arising from thrombus formation on an atheromatous plaque. This guideline addresses the early management of unstable angina and non-ST-segment-elevation myocardial infarction (NSTEMI) once a firm diagnosis has been made and before discharge from hospital.

If untreated, the prognosis is poor and mortality high, particularly in people who have had myocardial damage. Appropriate triage, risk assessment and timely use of acute pharmacological or invasive interventions are critical for the prevention of future adverse cardiovascular events (myocardial infarction, stroke, repeat revascularisation or death). The guideline does not cover the management of STEMI or specific complications of unstable angina and NSTEMI such as cardiac arrest or acute heart failure. 

You can read the guideline on NICE's website.