Chest pain. Understanding NICE guidance

chest pain UNG v6:CP UNG 11/3/10 10:35 Page 1 Understanding NICE guidance Information for people who use NHS services Chest pain NICE ‘clinical g...
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Understanding NICE guidance Information for people who use NHS services

Chest pain NICE ‘clinical guidelines’ advise the NHS on caring for people with specific conditions or diseases and the treatments they should receive.

This booklet is about the care and treatment of people with chest pain in the NHS in England and Wales. It explains guidance (advice) from NICE (the National Institute for Health and Clinical Excellence). It is written for people with chest pain but it may also be useful for their families or carers or for anyone with an interest in the condition. The booklet is to help you understand the care and treatment options that should be available in the NHS. It does not describe chest pain or the tests or treatments for it in detail. A member of your healthcare team should discuss these with you. There are examples of questions you could ask throughout this booklet to help you with this. You can get more information from the organisations listed on page 11. Medical terms printed in bold type are explained on page 10.

Information about NICE clinical guideline 95 Issue date: March 2010

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Contents Your care

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Chest pain

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Finding out what is wrong (making a diagnosis)

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Explanation of medical words and terms

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More information

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About NICE

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The advice in the NICE guideline covers: • the care and support of adults with chest pain thought to be related to the heart • tests and treatment that should be offered to people while their condition is being diagnosed. It does not specifically look at: • tests and treatment after a diagnosis has been made • the care of adults with chest pain that is not related to the heart.

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Your care In the NHS, patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution (www.dh.gov.uk/en/Healthcare/NHSConstitution/index.htm). All NICE guidance is written to reflect these. You have the right to be involved in discussions and make informed decisions about your treatment and care with your healthcare team. You should be able to ask any questions you want (see pages 4 and 9). Your choices are important and healthcare professionals should support these wherever possible. You should be treated with dignity and respect. To help you make decisions, healthcare professionals should explain the implications of heart-related chest pain and the possible investigations and treatments for it. They should cover possible benefits and risks related to your personal circumstances. You should be given relevant information that is suitable for you and reflects any religious, ethnic, or cultural needs you have. It should also take into account whether you have any physical or learning disability, sight or hearing problem or language difficulties. You should have access to an interpreter or advocate (someone who helps you put your views across) if needed. Your family and carers should be given their own information and support. If you agree, they should also have the chance to be involved in decisions about your care. You should be able to discuss or review your care as your treatment progresses, or your circumstances change. This may include changing your mind about your treatment or care. If you have made an ‘advance directive’ (have already given instructions) about any treatments that you do not wish to have, your healthcare professionals have a legal obligation to take this into account. All treatment and care should be given with your informed consent. If, during the course of your illness, you are not able to make decisions about your care, your healthcare professionals have a duty to talk to your family or carers unless you have specifically asked them not to. Healthcare professionals should follow the Department of Health’s advice on consent (www.dh.gov.uk/consent) and the code of practice for the Mental Capacity Act. Information about the Act and consent issues is available from www.publicguardian.gov.uk. In Wales healthcare professionals should follow advice on consent from the Welsh Assembly Government (www.wales.nhs.uk/consent). In an emergency, healthcare professionals may give treatment immediately, without obtaining your informed consent, when it is in your best interests.

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Chest pain There are many possible causes for pain or discomfort in the chest, including indigestion or muscle pain. But sometimes chest pain can be a sign of a more serious condition, such as coronary heart disease. Coronary heart disease is a condition in which blood vessels in the heart narrow or get blocked by a build up of fat. The blood supply to the heart is reduced and this can cause stable angina, unstable angina or a heart attack. Quick diagnosis and treatment for people who have chest pain because of coronary heart disease will help to prevent death and reduce disability from this disease.

Questions you might want to ask your healthcare team about chest pain • What do you think is causing my chest pain? • Where can I get written information about my condition?

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Finding out what is wrong (making a diagnosis) When you see a healthcare professional about your chest pain (this may be your GP, a member of the ambulance service or a healthcare professional in hospital) they should ask whether you currently have chest pain, or when you last had chest pain. They should ask if you have any other symptoms besides the chest pain and whether you have had these symptoms before, or had any investigation or treatment for them, in the past. You should also be assessed for any cardiovascular risk factors, such as whether you have high blood pressure or are a smoker. If the healthcare professional thinks that you may have unstable angina or have had a heart attack, you should be offered the care and investigations described below. If they think you may have stable angina, see page 7 for the care and investigations you should be offered.

If you think that your care does not match what is described in this booklet, please talk to a member of your healthcare team in the first instance.

If the chest pain is not thought to be because of your heart, other possible causes should be discussed with you and may be investigated. While your healthcare professional is finding out what is wrong, you should have the opportunity to discuss any anxieties you may have about the cause of your chest pain.

Investigations for unstable angina or a heart attack As soon as possible, you should have: • drugs to relieve your pain if needed (such as glyceryl trinitrate [GTN] or an opioid) and regular checks to make sure you are not in pain • an electrocardiogram (ECG) to show how your heart is working. This may be done by a GP or a member of the ambulance service • a single dose of aspirin to make your blood less ‘sticky’ and less likely to form blood clots. You should not have aspirin if you are allergic to it • a test to see whether you need extra oxygen and be offered extra oxygen if you need it. These should not delay you being taken to hospital if you need to go. If you currently have chest pain or if you have signs of complications that need further investigation, you may need to go to hospital as an emergency for further tests and treatment. This will depend on whether you currently have chest pain and the results of your ECG.

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You should not need to go to hospital as an emergency if you do not currently have chest pain and your ECG is normal, but you should have an assessment in hospital on the same day. If your chest pain was more than 3 days ago you should have an assessment, which may be done in hospital. If you don’t currently have chest pain you should also be given advice about what to do if it returns. During the assessment you should be asked to describe your pain and any other symptoms. You should also be asked if you have any history of coronary heart disease. Details of previous investigations or treatments you have had for similar symptoms of chest pain should be noted. You should also be assessed for cardiovascular risk factors. With your permission, your healthcare professional should carry out a physical examination to check your heart, and for any complications. You may have repeated ECGs and your blood should be checked for levels of a protein called troponin. Raised levels of troponin may be a sign that you have had a heart attack, but they may also be raised if you have other conditions. Your troponin levels should be measured again 10–12 hours after your symptoms first started. If you have unstable angina or have had a heart attack, you will be offered appropriate treatment. If the results are not clear, your healthcare professional may ask to repeat some of the tests. This may involve a stay in hospital for observation. Sometimes a chest X-ray or a type of scan known as a chest CT (computed tomography) scan may be carried out to check whether you have any complications of unstable angina or a heart attack or whether your pain is caused by other conditions. If your healthcare professional thinks that you may have stable angina, see page 7 for the care and investigations you should be offered. If your chest pain is not related to your heart, but you have any cardiovascular risk factors, you should be offered advice and you may be offered treatment to help lower your cardiovascular risk.

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Investigations for stable angina Your healthcare professional, usually your GP, should ask you about your chest pain and other related symptoms you have now, and any you have had in the past. They will also want to know whether you have a history of coronary heart disease. You will be checked for cardiovascular risk factors. With your permission, your healthcare professional should also examine you physically. This is to check for any signs of other cardiovascular disease, other causes of stable angina or other reasons for your chest pain. If your healthcare professional thinks that you have stable angina, further tests to make a diagnosis should not be needed and you will be offered appropriate treatment. If there is any uncertainty about whether you have stable angina further tests may be needed (see ‘Tests used to diagnose stable angina’). An ECG should be taken as soon as possible to check your heart. You should also be offered a blood test to check for any conditions that could make angina worse, for example anaemia. You may be offered treatment with aspirin unless you are already taking it regularly or you are allergic to it, while you have further tests.

Some tests may not be appropriate for you, depending on your exact circumstances. If you have questions about specific tests and options covered in this booklet, please talk to a member of your healthcare team.

If your healthcare professional thinks it is unlikely that you have stable angina, they should consider what else could be causing your chest pain. You may not need further tests, but sometimes a chest X-ray, for example, may be carried out to help find out what is wrong. If your chest pain is not related to your heart, but you have any cardiovascular risk factors, you should be offered advice and you may be offered treatment to help lower your cardiovascular risk.

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Tests used to diagnose stable angina A number of tests are used to help diagnose stable angina. Some of the tests involve being exposed to radiation. You should be offered information about the risks of radiation, and about the risks and benefits of the tests.

What tests should I be offered? The following tests are recommended in the NICE guideline, some of which may be appropriate for you. You may be offered one or more of these tests depending on how likely you are to have stable angina. Sources of more detailed information are listed on page 11. Invasive coronary angiography uses X-rays to see how dye (called contrast medium) moves through the arteries up to the heart. This shows whether there are any narrowed or blocked arteries. It is invasive because it involves a fine, hollow tube called a catheter being inserted through the artery of the person’s leg or arm and up to the heart. CT coronary angiography uses a type of X-ray called computed tomography (CT) scanning and dye injected into the person’s veins to show whether the coronary arteries are narrowed or blocked. Functional imaging tests show how the heart works under stress. Different tests can be used depending on the circumstances and the person’s preferences. CT calcium scoring is a type of X-ray that detects calcium in the coronary artery walls. Fat and calcium build up in the artery walls when a person has coronary heart disease and cause narrowing or blockages. Exercise ECG is a test that shows how the heart works while a person is exercising (walking on a treadmill or using an exercise bike).

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You should not be offered MR coronary angiography to diagnose stable angina, which is a type of coronary angiography that uses magnetic resonance (MR) imaging to produce pictures of the coronary arteries. If you are not diagnosed with stable angina, other reasons for your chest pain should be investigated.

Questions you might want to ask about the tests for stable angina • Please can I have more details about the test I’m having? • Why am I being offered this test? • What does the test involve? Are there any risks? • Where and when will the test be carried out? • How long will it take to get the results of the test? • Is there anything special I need to do before the test, for example should I keep taking my medication?

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Explanation of medical words and terms Anaemia is a condition in which a person doesn’t have enough red cells or haemoglobin in their blood to carry oxygen around the body. Haemoglobin is the substance that helps to store and carry oxygen in red blood cells. People with anaemia may often feel dizzy, breathless or depressed. Cardiovascular risk factors increase the risk of a person having cardiovascular disease. Examples include high blood pressure, smoking, and having high levels of fats (such as cholesterol) in the blood. Electrocardiogram (ECG) is a test that measures the electrical activity of a person’s heart. It involves pads (electrodes) being stuck to the arms, legs, chest and trunk. Glyceryl trinitrate (GTN) is a drug used to relieve or prevent angina. It is usually given as a spray or in the form of a tablet. Heart attacks happen when an artery in the heart becomes blocked. Blood cannot reach part of the heart, which becomes damaged because of lack of oxygen. An opioid is a type of medication given to relieve pain, for example morphine. It is given as an injection into the vein. Stable angina is pain or a feeling of tightness in the chest, which can often spread to the jaw, back, shoulders and arms. An attack of angina is usually brought on by physical activity. Troponin is a protein released into the blood when heart muscle is damaged. Unstable angina is pain or a feeling of tightness in the chest which occurs even if the person is resting or is doing something that doesn’t take much effort. The angina may have been stable before, but has recently worsened or changed.

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More information The organisations below can provide more information and support for people with chest pain. NICE is not responsible for the quality or accuracy of any information or advice provided by these organisations. • Action Heart, 01384 292233 www.actionheart.com • Atrial Fibrillation Association, 01789 451837 www.atrialfibrillation.org.uk • British Heart Foundation, 0300 330 3311 www.bhf.org.uk • HEART UK – The Cholesterol Charity, 0845 450 5988 www.heartuk.org.uk • Northern Ireland Chest, Heart and Stroke, 0845 769 7299 www.nichsa.com NHS Choices (www.nhs.uk) may be a good place to find out more. Your local patient advice and liaison service (usually known as ‘PALS’) may be able to give you more information and support. You should also contact PALS if you are unhappy with the treatment you are offered, but you should talk about your care with a member of your healthcare team first. If your local PALS is not able to help you, they should refer you to your local independent complaints advocacy service. If you live in Wales you should speak to NHS Direct Wales for information on who to contact.

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About NICE NICE produces guidance (advice) for the NHS about preventing, diagnosing and treating medical conditions. The guidance is written by independent experts including healthcare professionals and people representing patients and carers. They consider the evidence on the condition and treatments, the views of patients and carers and the experiences of doctors, nurses and other healthcare professionals. Staff working in the NHS are expected to follow this guidance. To find out more about NICE, its work and how it reaches decisions, see www.nice.org.uk/AboutGuidance This booklet and other versions of the guideline aimed at healthcare professionals are available at www.nice.org.uk/guidance/CG95. The versions for healthcare professionals contain more detailed information on the care and treatment you should be offered. You can order printed copies of this booklet from NICE publications (phone 0845 003 7783 or email [email protected] and quote reference N2114). The NICE website has a screen reader service called Browsealoud, which allows you to listen to our guidance. Click on the Browsealoud logo on the NICE website to use this service. We encourage NHS and voluntary organisations to use text from this booklet in their own information about chest pain.

National Institute for Health and Clinical Excellence MidCity Place, 71 High Holborn, London, WC1V 6NA; www.nice.org.uk © National Institute for Health and Clinical Excellence, 2010. All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the express written permission of NICE.

ISBN 978-1-84936-188-0 N2114 10k 1P Mar 10