Chest pain of recent onset

CT calcium scoring factsheet

Implementing NICE guidance

Updated July 2010

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NICE clinical guideline 95

This computed tomography (CT) calcium scoring factsheet accompanies the clinical guideline: Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin (available online at www.nice.org.uk/guidance/CG95). Issue date: 2010

This is a support tool to help people implement NICE guidance on chest pain of recent onset. It should be read together with NICE clinical guideline 95. It is not NICE guidance. Implementation of the guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement this guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in the guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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.

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Introduction
This tool has been developed to help clarify the role CT calcium scoring can play in ruling out stable angina in people presenting with chest pain of suspected cardiac origin.

Related NICE guidance

For information about NICE guidance that has been issued or is in development see www.nice.org.uk

Resources from NICE

Guidance
You can download the guidance documents from www.nice.org.uk/CG95.

Implementation tools
NICE has developed tools to help organisations implement the clinical guideline on chest pain of recent onset (listed below). These are available on our website (www.nice.org.uk/guidance/CG95). Costing tools: costing report to estimate the national savings and costs associated with implementation costing template to estimate the local costs and savings involved. Slides highlighting key messages for local discussion. Implementation advice on how to put the guidance into practice and national initiatives that support this locally. Audit support for monitoring local practice, an audit support patient questionnaire and an audit support patient questionnaire analysis spreadsheet. A practical guide to implementation, How to put NICE guidance into practice: a guide to implementation for organisations, is also available on our website (www.nice.org.uk/usingguidance/implementationtools).
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CT calcium scoring factsheet

What are the NICE1 recommendations covering CT calcium scoring? In people without confirmed coronary artery disease (CAD), in whom stable angina cannot be diagnosed or excluded based on clinical assessment alone, estimate the likelihood of CAD (see table 1 overleaf). Take the clinical assessment and the resting 12-lead ECG into account when making the estimate. Arrange further diagnostic testing as follows: If the estimated likelihood of CAD is 6190%, offer invasive coronary angiography as the firstline diagnostic investigation if appropriate (see recommendations 1.3.4.4 and 1.3.4.5) 1 If the estimated likelihood of CAD is 3060%, offer functional imaging as the first-line diagnostic investigation (see recommendation 1.3.4.61) If the estimated likelihood of CAD is 1029%, offer CT calcium scoring as the first-line diagnostic investigation (see recommendation 1.3.4.71) For people with chest pain in whom stable angina cannot be diagnosed or excluded by clinical assessment alone and who have an estimated likelihood of CAD of 1029% (see recommendation 1.3.3.161) offer CT calcium scoring. If the calcium score is: zero, consider other causes of chest pain 1400, offer 64-slice (or above) CT coronary angiography greater than 400, offer invasive coronary angiography. If this is not clinically appropriate or acceptable to the person and revascularisation is not being considered, offer non-invasive functional imaging. See section 1.3.61 for further guidance on non-invasive functional testing. How does CT calcium scoring work? Calcification of coronary arteries is a sign of atherosclerotic disease and can be quantified using multislice computed tomography (CT). How long does it take? CT calcium scoring takes approximately 5 minutes to perform and interpret. What is the radiation exposure for a typical CT calcium scoring examination? 1.53.0 mSva. There are different figures available for the long-term effects of this. However, to put it into perspective the radiation exposure of CT calcium scoring is the same as a barium swallow2,a (1.5 mSv) and less than a myocardial perfusion scan with SPECT(technetium) (6 8mSv)a,b, or a CT scan of the abdomen / pelvis2,a (10 mSv). With the most modern scanners and expert operators the radiation exposure can be kept at the lower level. Is contrast material (media) required? - No Does it make a functional assessment of myocardial ischaemia and/or left ventricular function? - No What are the benefits of CT calcium scoring in this group? It is quicker than exercise ECG. Overall the performance of exercise ECG was not considered to be as effective, and costeffective, in diagnosing CAD by the Guideline Development Group (the group of experts who developed the guideline).
a

Approximate dose. Doses vary depending on equipment and technique used and patient size Doses vary depending whether the patient has received a one or two day protocol. Thallium myocardial perfusion scans have a higher radiation that technetium
b

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CT calcium scoring is better at ruling out CAD in this group as it has a much higher sensitivity for CAD. This means that by using CT calcium scoring instead of exercise ECG, fewer people will be referred on for unnecessary further testing, which often involves exposure to higher levels of radiation. 64-slice (or above) CT coronary angiography with calcium screening as a gatekeeper was cost effective in people with an estimated 1029% likelihood of CAD. If the person requires 64-slice (or above) CT coronary angiography based on the calcium score this could be organised as an immediate follow-on test. This will increase efficiency within the CT department (reducing the chance of a did not attend or the person being late) and reducing the total number of visits the person has to make. What percentage of people presenting to a chest pain clinic are likely to require CT calcium scoring? Based on an analysis of people attending a rapid access chest pain clinic (RACPC), up to17% will be referred for CT calcium scoring. With an estimated likelihood of CAD in the 1029% range, it is likely that at least 70% of this group would have non-calcified arteries and be ruled out for stable angina, requiring no further testing. From table 1 below, younger people are more likely to be low risk and will therefore require a referral for CT calcium scoring. Is it appropriate to expose young low-risk people (particularly women because of the risk of breast cancer) to radiation, particularly when they may have the test repeated several times during their lifetime? Only people with two or more features of angina and in whom stable angina is suspected based on clinical assessment and resting 12-lead ECG results should be investigated for stable angina. It is anticipated that a third of people presenting to a RACPC will be ruled out at the clinical assessment stage. Of these, a majority will be the low risk and younger people. For those people in whom stable angina is still suspected, it is likely that they will be assessed as having a low estimated likelihood of CAD and will be referred for CT calcium scoring. This test is better than exercise ECG at ruling out CAD in this group. This will reduce the number of people who are required to have further testing to rule out CAD and avoid higher radiation doses. Research suggests that this small group of young low-risk people in whom stable angina is still suspected, are currently receiving myocardial perfusion scans which have higher radiation doses than CT calcium scoring. Following the NICE recommendations for these people would mean that the number of people exposed to higher radiation doses will fall, as they are effectively ruled out earlier in the diagnostic process.

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References
1. See the full guideline and NICE guideline at www.nice.org.uk/guidance/CG95 2. September 2008 http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HPAweb_C/1195733826941?p=115 8934607708 Health Protection Agency Website, (2010) Webpage updated

Acknowledgements
NICE would like to thank the members of the National Clinical Guideline Centre for Acute and Chronic conditions and the Guideline Development Group. Additionally we would like to thank Mark Worrall, North Western Medical Physics, The Christie NHS Foundation Trust.

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