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NICE rules out treadmill test for angina

By Nigel Praities

NICE has ditched the exercise stress test for diagnosing patients with suspected angina in new preliminary guidance.

Draft chest pain guidelines say the commonly-used test is ‘generally not helpful' in identifying those patients with stable angina.

Experts say the advice is a ‘big change' and will result in major delays for GPs and patients in both getting a diagnosis from chest pain clinics and treating angina.

The guidelines – which are out for consultation until July – detail two patient pathways for patients with sudden onset chest pain.

Patients with a suspected heart attack are to be referred immediately to hospital, while those with suspected angina are to have a clinical diagnosis made by GPs.

Patients without a firm diagnosis of angina after a clinical assessment and a resting ECG should be sent for angiography, functional imaging or calcium scoring rather than undergo exercise testing, the guidance advises.

‘Do not use exercise ECG as the primary diagnostic test for myocardial ischaemia in people without known coronary artery disease,' it states.

The change has surprised GPs. Dr Kathryn Griffith, a GP in York and president elect of the Primary Care Cardiovascular Society, warned it would be distressing for patients as their diagnosis and treatment would be delayed.

‘It will be a major change. We have a one-stop clinic at the moment where patients come out with a diagnosis and start on treatment straight away. I don't think they would if we don't do a treadmill test.

‘Over half of patients who come to us don't have angina and we don't have access to stress echo for everyone that comes into the clinic,' she explained.

Dr Terry McCormack, former PCCS chair of the Primary Care Cardiovascular Society agreed the change would prove controversial.

NICE's recommendation follows a Health Technology Assessment published in 2004 questioning the widespread use of exercise ECGs in the diagnosis of coronary heart disease.

‘It is not a strongly diagnostic test, whether positive or negative' the analysis from the University of Birmingham concluded.

NICE declined to comment.

Chest pain guidance

- Refer patients to hospital as an emergency if acute coronary syndromes are suspected and they currently have chest pain or their resting ECG is abnormal or not available

- Carry out a clinical assessment and resting ECG in patients with stable chest pain of suspected cardiac origin to diagnose angina

- Refer for further investigations if there is no firm diagnosis and offer aspirin

- Recommended first line diagnostic investigations include angiography, non-invasive functional imaging or CT calcium scoring

- Do not use exercise ECG as the primary diagnostic test for myocardial ischaemia in people without known coronary artery disease

Source: NICE guideline on chest pain of recent onset, draft for consultation May 2009

Dr Kathryn Griffith: ‘It will be a major change.' Dr Kathryn Griffith: ‘It will be a major change.'

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