Chest Pain with Normal Coronary Arteries: A Multidisciplinary Approach


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Eslick, G. Despite its notable prevalence, the epidemiology of the condition remains poorly documented. Curiosity as to the cardiac aetiology of this chest pain became the focus of several key studies investigating the clinical and haemodynamic features of patients with normal coronary angiography. Thrombin injections for pseudoaneurysms NICE interventional procedures guidance MiraQ for assessing graft flow during coronary artery bypass graft surgery updated NICE medical technologies guidance 8.

Air pollution: outdoor air quality and health NICE quality standard Acute coronary syndromes in adults NICE quality standard Stable angina NICE quality standard CADScor system for ruling out coronary artery disease in people with symptoms of stable coronary artery disease NICE medtech innovation briefing Impella 2. Sternal Talon for sternal closure in cardiothoracic surgery NICE medtech innovation briefing Somatom Definition Edge CT scanner for imaging coronary artery disease in adults in whom imaging is difficult NICE medtech innovation briefing The PressureWire fractional flow reserve measurement system for coronary artery disease NICE medtech innovation briefing 2.

Acute coronary syndromes in adults These quality statements are taken from the acute coronary syndromes in adults quality standard. The quality standard defines clinical best practice for acute coronary syndromes in adults and should be read in full. Stable angina These quality statements are taken from the stable angina quality standard.

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The quality standard defines clinical best practice in stable angina care and should be read in full. Air pollution: outdoor air quality and health These quality statements are taken from the air pollution: outdoor air quality and health quality standard. The quality standard defines clinical best practice for air pollution: outdoor air quality and health and should be read in full. Diagnosis of acute myocardial infarction This quality statement is taken from the acute coronary syndromes including myocardial infarction quality standard. The quality standard defines clinical best practice for acute coronary syndromes including myocardial infarction and should be read in full.

Adults with a suspected acute coronary syndrome are assessed for acute myocardial infarction using the criteria in the universal definition of myocardial infarction. Acute myocardial infarction can have a poor prognosis so prompt and accurate diagnosis is important to ensure that appropriate treatment and care is offered as soon as possible. Treatment for adults with suspected acute coronary syndrome is often started before a diagnosis is confirmed.

Confirming the diagnosis using the criteria in the universal definition of myocardial infarction is important to ensure that any ongoing treatment is appropriate and any inappropriate treatment is stopped. Evidence of local arrangements to ensure that adults with a suspected acute coronary syndrome are assessed for the presence of acute myocardial infarction using the criteria in the universal definition of myocardial infarction.

Proportion of adults with a diagnosis of acute myocardial infarction who had their diagnosis made using the criteria in the universal definition of myocardial infarction. Numerator — the number in the denominator who had their diagnosis made using the criteria in the universal definition of myocardial infarction. Service providers cardiac service providers ensure that adults with a suspected acute coronary syndrome are assessed for the presence of acute myocardial infarction using the criteria in the universal definition of myocardial infarction.

Healthcare professionals ensure that they are aware of the universal definition of myocardial infarction and assess adults with a suspected acute coronary syndrome for the presence of acute myocardial infarction using the criteria in the universal definition. Commissioners clinical commissioning groups ensure that they commission services with staff with expertise in using the criteria in the universal definition of myocardial infarction to diagnose acute myocardial infarction in adults with a suspected acute coronary syndrome.

Symptoms of acute coronary syndromes should be assessed in the same way in men and women and among people from different ethnic groups. Risk assessment for adults with NSTEMI or unstable angina This quality statement is taken from the acute coronary syndromes including myocardial infarction quality standard. Adults with non-ST-segment-elevation myocardial infarction NSTEMI or unstable angina are assessed for their risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality to guide clinical management.

Assessing and categorising risk of future adverse cardiovascular events by formal risk assessment for example, using the GRACE scoring system in people who have been diagnosed with NSTEMI or unstable angina is important for determining early management strategies. It also allows the benefits of treatment to be balanced against the risks of treatment related adverse events.

Failure to categorise future risk can lead to people being given inappropriate treatment. Evidence of local arrangements to ensure that adults with NSTEMI or unstable angina are assessed for their risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality to guide clinical management. Proportion of presentations for NSTEMI or unstable angina that had an assessment of the risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality.

Numerator — the number in the denominator that had an assessment of the risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality. Data source: Local data collection. Contained within NICE clinical guideline 94 audit support , criterion 1.

Service providers cardiac service providers ensure that local pathways are in place for adults with NSTEMI or unstable angina to be assessed for their risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality. Providers should also raise awareness among healthcare professionals of the importance of risk assessment in guiding clinical management.

Healthcare professionals ensure that they assess the risk of future adverse cardiovascular events in adults with NSTEMI or unstable angina using an established risk scoring system that predicts 6-month mortality to guide clinical management. Commissioners clinical commissioning groups ensure that they commission services with staff with the expertise to assess the risk of future adverse cardiovascular events in adults with NSTEMI or unstable angina using established risk scoring systems that predict 6-month mortality to guide clinical management.

Adults with heart conditions called NSTEMI and unstable angina have their risk of another heart attack estimated to guide their treatment. Individual risk of future adverse cardiovascular events should be formally assessed using an established risk scoring system that predicts 6-month mortality for example, Global Registry of Acute Cardiac Events [GRACE]. Using 6-month mortality, the categories for the risk of future adverse cardiovascular events are:.

Coronary angiography and PCI within 72 hours for NSTEMI or unstable angina This quality statement is taken from the acute coronary syndromes including myocardial infarction quality standard. Adults with non-ST-segment-elevation myocardial infarction NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events are offered coronary angiography with follow-on percutaneous coronary intervention [PCI] if indicated within 72 hours of first admission to hospital.

Coronary angiography is important to define the extent and severity of coronary disease. In people with an intermediate or higher risk of future adverse cardiovascular events, coronary angiography within 72 hours of admission to hospital offers advantages over an initial conservative strategy, provided there are no contraindications to angiography such as active bleeding or comorbidity. Services should provide coronary angiography with follow-on PCI if indicated as soon as it offers net clinical benefits; they should not wait until 72 hours if this is sooner.


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Evidence of local arrangements to ensure that adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events are offered coronary angiography with follow-on PCI if indicated within 72 hours of first admission to hospital. Length of time taken for adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events to receive coronary angiography with follow-on PCI if indicated.

Local areas should collaborate with healthcare professionals to determine if the timeframe was appropriate for the patient. Proportion of adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events who receive coronary angiography with follow-on PCI if indicated within 72 hours of first admission to hospital.

Numerator — the number of people in the denominator receiving coronary angiography with follow-on PCI if indicated within 72 hours of admission. Denominator — the number of adults with NSTEMI or unstable angina with an intermediate or higher risk of future adverse cardiovascular events on admission to hospital. Contained within NICE clinical guideline 94 audit support , criterion 9. Service providers cardiac service providers ensure that local pathways are in place for adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events to be seen by cardiac specialists and offered coronary angiography with follow-on PCI if indicated within 72 hours of first admission to hospital.

Healthcare professionals ensure that they offer adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events, coronary angiography with follow-on PCI if indicated within 72 hours of first admission to hospital.

Commissioners clinical commissioning groups ensure that they commission services with the capacity and expertise to offer adults with NSTEMI or unstable angina who have an intermediate or higher risk of future adverse cardiovascular events, coronary angiography with follow-on PCI if indicated within 72 hours of first admission to hospital.

Adelaide Research & Scholarship: Epidemiology of cardiac syndrome X and microvascular angina

Adults with heart conditions called NSTEMI and unstable angina who have a medium or higher risk of another heart attack are offered a test called coronary angiography, and treatment to improve blood flow to the heart if needed, within 72 hours of first being admitted to hospital. A predicted 6-month mortality above 3. Coronary angiography and PCI for adults with NSTEMI or unstable angina who are clinically unstable This quality statement is taken from the acute coronary syndromes including myocardial infarction quality standard. Adults with non-ST-segment-elevation myocardial infarction NSTEMI or unstable angina who are clinically unstable have coronary angiography with follow-on percutaneous coronary intervention [PCI] if indicated as soon as possible, but within 24 hours of becoming clinically unstable.

The benefits of an early invasive strategy appear to be greatest in people at higher risk of future adverse cardiovascular events. In people with NSTEMI or unstable angina who are clinically unstable, coronary angiography with follow-on PCI if indicated should be done as soon as possible so that appropriate treatment can be given. It may reduce lengthy hospital stays and prevent further cardiovascular events in both the short and long term. The timing of coronary angiography will be different for each person, but should be within 24 hours of becoming clinically unstable.

Evidence of local arrangements to ensure that adults with NSTEMI or unstable angina who are clinically unstable have coronary angiography with follow-on PCI if indicated as soon as possible, but within 24 hours of becoming clinically unstable. Length of time taken for adults with NSTEMI or unstable angina who are clinically unstable on admission or during their hospital stay to receive coronary angiography with follow-on PCI if indicated.

Proportion of adults with NSTEMI or unstable angina who are clinically unstable who receive coronary angiography with follow-on PCI if indicated within 24 hours of becoming clinically unstable. Numerator — the number in the denominator receiving coronary angiography with follow-on PCI if indicated within 24 hours of becoming clinically unstable. Service providers secondary care and cardiac service providers ensure that local pathways are in place for adults with NSTEMI or unstable angina who are clinically unstable to be offered coronary angiography with follow-on PCI if indicated as soon as possible but within 24 hours of becoming clinically unstable.

Healthcare professionals ensure that they offer adults with NSTEMI or unstable angina who are clinically unstable, coronary angiography with follow-on PCI if indicated as soon as possible but within 24 hours of becoming clinically unstable. Commissioners clinical commissioning groups ensure that they commission services with the capacity and expertise for adults with NSTEMI or unstable angina who are clinically unstable to be offered coronary angiography with follow-on PCI if indicated as soon as possible but within 24 hours of becoming clinically unstable.

Adults with heart conditions called NSTEMI and unstable angina and whose condition is unstable are offered a test called coronary angiography and treatment to improve blood flow to the heart if needed, as soon as possible but within 24 hours of their condition becoming unstable. Local areas should collaborate with healthcare professionals to determine the appropriate timeframes for patients. Level of consciousness and eligibility for coronary angiography and primary PCI This quality statement is taken from the acute coronary syndromes including myocardial infarction quality standard.

Adults who are unconscious after cardiac arrest caused by suspected acute ST segment elevation myocardial infarction STEMI are not excluded from having coronary angiography with follow—on primary percutaneous coronary intervention [PCI] if indicated. People who remain unconscious after cardiac arrest should not be treated differently from people who are conscious.

They should be able to have the same treatments within the same timescales and should be admitted to centres capable of undertaking primary PCI. Evidence of local arrangements to ensure that adults who are unconscious after cardiac arrest caused by suspected acute STEMI are not excluded from having coronary angiography with follow—on primary PCI if indicated because they are unconscious. Proportion of adults who were unconscious after cardiac arrest caused by suspected acute STEMI who receive coronary angiography with follow-on primary PCI if indicated.

Numerator — the number in the denominator receiving coronary angiography with follow-on primary PCI if indicated. Denominator — the number of adults who were unconscious after cardiac arrest caused by suspected acute STEMI. Service providers ambulance services and cardiac service providers ensure that adults who are unconscious after cardiac arrest caused by suspected acute STEMI are not excluded from having coronary angiography with follow—on primary PCI if indicated. Providers should also raise awareness among healthcare professionals of the importance of not using level of consciousness to exclude adults from having coronary angiography with follow—on primary PCI if indicated.

Healthcare professionals ensure that they do not use level of consciousness after cardiac arrest caused by suspected acute STEMI to exclude adults from having coronary angiography with follow—on primary PCI if indicated. Commissioners clinical commissioning groups and NHS England ensure that they commission services that can carry out coronary angiography with follow—on primary PCI if indicated in adults who are unconscious after cardiac arrest caused by suspected acute STEMI.

Adults who are unconscious after a type of heart attack called STEMI can have a test called coronary angiography, and treatment to improve blood flow to the heart if needed, even though they are unconscious. Adults with acute ST-segment-elevation myocardial infarction STEMI who present within 12 hours of onset of symptoms have primary percutaneous coronary intervention PCI , as the preferred coronary reperfusion strategy, as soon as possible but within minutes of the time when fibrinolysis could have been given.

Primary PCI is a form of reperfusion therapy which should be done as soon as possible. This is because heart muscle starts to be lost once a coronary artery is blocked and the sooner reperfusion therapy is delivered the better the outcome for the patient. If too much time elapses the benefits of primary PCI may be lost. Because of the difficulty in timely delivery, in some areas primary PCI is no longer the preferred coronary reperfusion strategy over fibrinolysis.

However, when performed early, primary PCI is more effective. To ensure the best outcomes for adults with STEMI, the ambulance service and hospitals delivering primary PCI should work together to minimise delays in treatment. Evidence of local arrangements to ensure that adults with acute STEMI who present within 12 hours of onset of symptoms have primary PCI, as the preferred coronary reperfusion strategy, within minutes of the time when fibrinolysis could have been given.

Evidence that commissioners with their services providers have developed a single care pathway for coronary reperfusion.


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Proportion of adults with acute STEMI who present within 12 hours of onset of symptoms who receive primary PCI within minutes of when fibrinolysis could have been given. Numerator — the number in the denominator receiving primary PCI within minutes of when fibrinolysis could have been given. Denominator — the number of adults with acute STEMI who present within 12 hours of onset of symptoms.

Proportion of adults with acute STEMI who present within 12 hours of onset of symptoms who receive primary PCI within minutes of the call for professional help.

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Numerator — the number of people in the denominator receiving primary PCI within minutes of the call for professional help. Service providers ambulance services, accident and emergency service provider and cardiac service providers ensure that local pathways and transfer protocols are in place for adults with acute STEMI who present within 12 hours of the onset of symptoms to be offered primary PCI, as the preferred coronary reperfusion strategy, as soon as possible but within minutes of when fibrinolysis could have been given.

Healthcare professionals ensure that they offer primary PCI, as the preferred coronary reperfusion strategy, as soon as possible but within minutes of when fibrinolysis could have been given to adults with acute STEMI who present within 12 hours of the onset of symptoms. Commissioners clinical commissioning groups and NHS England ensure that they commission services that have the capacity and expertise to provide primary PCI, as the preferred coronary reperfusion strategy, as soon as possible but within minutes of when fibrinolysis could have been given and at any time of the day or night, including weekends to adults with acute STEMI who present within 12 hours of onset of symptoms.

Commissioners should work with their service providers to develop a single care pathway for coronary reperfusion. Adults with a type of heart attack called STEMI whose symptoms started no more than 12 hours before first contacting a healthcare professional are offered a procedure to improve blood flow to the heart called percutaneous coronary intervention or PCI.

Microvascular angina and the sensitive heart: historical perspective.

Diagnostic investigation This quality statement is taken from the stable angina quality standard. The quality standard defines clinical best practice for stable angina and should be read in full. People with features of typical or atypical angina are offered slice or above CT coronary angiography. Evidence of local arrangements to ensure that people with features of typical or atypical angina are offered slice or above CT coronary angiography.

Microvascular angina and the sensitive heart: historical perspective.

Proportion of people with features of typical or atypical angina who receive slice or above CT coronary angiography. Numerator — the number of people in the denominator who receive slice or above CT coronary angiography. Service providers ensure systems are in place so that people with features of typical or atypical angina are offered slice or above CT coronary angiography. Buy Hardcover. Buy Softcover. Rent the eBook. FAQ Policy. About this book Written by leading authorities in the field, Chest Pain with Normal Coronary Arteries comprehensively reviews the clinical presentation and the pathogenesis of the condition, as well as its management.

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