If patient without known coronary artery disease, and angina cannot be diagnosed or excluded based on clinical assessment alone

In people without confirmed CAD, in whom stable angina cannot be diagnosed or excluded based on clinical assessment alone, estimate the likelihood of CAD (see tables 1,2,3). Take the clinical assessment and the resting 12-lead ECG into account when making the estimate.

• further diagnostic testing should be organised as follows:  
  • if the estimated likelihood of CAD is 61-90%, offer invasive coronary angiography as the first-line diagnostic investigation if appropriate
    
    
  • if the estimated likelihood of CAD is 30-60%, offer functional imaging as the first-line diagnostic investigation
    
    
  • if the estimated likelihood of CAD is 10-29%, offer CT calcium scoring as the first-line diagnostic investigation
    
    
  • do not use exercise ECG to diagnose or exclude stable angina for people without known CAD
  • Table 1: Non-anginal chest pain - % likelihood of CAD

Table 2: Atypical anginal pain - % likelihood of CAD

Table 3: Typical angina - % likelihood of CAD

• for men older than 70 with atypical or typical symptoms, assume an estimate > 90%.
• For women older than 70, assume an estimate of 61-90% EXCEPT women at high risk AND with typical symptoms where a risk of > 90% should be assumed
• Values are per cent of people at each mid-decade age with significant coronary artery disease (CAD)
• Hi = High risk = diabetes, smoking and hyperlipidaemia (total cholesterol > 6.47 mmol/litre)
• Lo = Low risk = none of these three
• Table 1:
  • represents people with symptoms of non-anginal chest pain, who would not be investigated for stable angina routinely
• Note:
  • These results are likely to overestimate CAD in primary care populations. If there are resting ECG ST-T changes or Q waves, the likelihood of CAD is higher in each cell of the table.

Reference:

• 1) NICE (March 2010). Chest pain of recent onset.