Early management of unstable angina and non-ST segment elevation myocardial infarction: summary of NICE guidance

The NICE guidance on unstable angina and NSTEMI raises significant
clinical concerns. Although mandating a risk score in patients is laudable
the use of the GRACE calculator is so dependent on age that it produces
perverse decision making. Using GRACE a 49 year old male presenting with
marked ST segment depression and a significantly raised troponin but
normal pulse and blood pressure would be managed conservatively according
to NICE guidance. In contrast almost everyone over the age of 60 with no
ECG changes and normal troponin would merit routine coronary angiography.

There is significant risk that patients presenting with non cardiac chest
pain over the age of 60 will undergo an inappropriate coronary angiogram
with associated risk and cost.

Whilst the use of powerful anti-thrombin therapies in the new guidance may
be evidence based and valid; again many patients present to the acute
medical take not with a firm diagnosis of an acute coronary syndrome but
diagnostic uncertainty and exposing such patients to these agents is not
without risk.

The move from unfractionated intravenous heparin to subcutaneous low
molecular weight heparins was a major advance in safety in managing
patients with acute coronary syndromes. The guidance suggests a move back
to complex intravenous regimes with all the problems of monitoring and
dose adjustment in overstretched accident and emergency departments, and
emergency admissions units. This produces scope for significant risk.

I believe that aspects of the current NICE guidance on the management of
unstable angina and NSTEMI will result in harm to patients. A clinical
debate is required before this guidance is accepted as routine clinical
practice.

Competing interests:
None declared