Early management of unstable angina andEarly management of unstable angina andNSTEMINSTEMI
NICE Pathways bring together everything NICE says on a topic in an interactiveflowchart. NICE Pathways are interactive and designed to be used online.
They are updated regularly as new NICE guidance is published. To view the latestversion of this NICE Pathway see:
http://pathways.nice.org.uk/pathways/chest-painNICE Pathway last updated: 23 May 2018
This document contains a single flowchart and uses numbering to link the boxes to theassociated recommendations.
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1 Person diagnosed with unstable angina or NSTEMI
No additional information
2 Provide information
Offer patients clear information about the risks and benefits of the treatments offered so that
they can make informed choices about management strategies. Information should be
appropriate to the patient's underlying risk of a future adverse cardiovascular event and any
comorbidities.
NICE has written information for the public on early management of unstable angina and
NSTEMI.
3 Initial drug treatment
Aspirin
Offer aspirin as soon as possible to all patients and continue indefinitely unless contraindicated
by bleeding risk or aspirin hypersensitivity.
Offer patients a single loading dose of 300 mg aspirin as soon as possible unless there is clear
evidence that they are allergic to it.
For patients with aspirin hypersensitivity, clopidogrel monotherapy should be considered as an
alternative treatment.
Antithrombin therapy
Offer fondaparinux to patients who do not have a high bleeding risk, unless coronary
angiography is planned within 24 hours of admission.
Offer unfractionated heparin as an alternative to fondaparinux to patients who are likely to
undergo coronary angiography within 24 hours of admission.
Carefully consider the choice and dose of antithrombin in patients who have a high risk of
bleeding associated with any of the following:
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advancing age
known bleeding complications
renal impairment
low body weight.
Consider unfractionated heparin, with dose adjustment guided by monitoring of clotting function,
as an alternative to fondaparinux for patients with significant renal impairment (creatinine above
265 micromoles per litre).
Ticagrelor
The following recommendations are an extract from NICE technology appraisal guidance on
ticagrelor for the treatment of acute coronary syndromes.
Ticagrelor in combination with low-dose aspirin is recommended for up to 12 months as a
treatment option in adults with acute coronary syndromes that is, people:
with NSTEMI or
admitted to hospital with unstable angina – defined as ST or T wave changes onelectrocardiogram suggestive of ischaemia plus one of the characteristics defined below.Before ticagrelor is continued beyond the initial treatment, the diagnosis of unstable anginashould first be confirmed, ideally by a cardiologist.
For the purposes of this guidance, characteristics to be used in defining treatment with
ticagrelor for unstable angina are: age 60 years or older; previous myocardial infarction or
previous CABG; coronary artery disease with stenosis of 50% or more in at least two vessels;
previous ischaemic stroke; previous transient ischaemic attack, carotid stenosis of at least 50%,
or cerebral revascularisation; diabetes mellitus; peripheral arterial disease; or chronic renal
dysfunction, defined as a creatinine clearance of less than 60 ml per minute per 1.73 m2 of
body-surface area.
NICE has written information for the public on ticagrelor.
See what NICE says on medicines optimisation.
4 Assess risk of future adverse cardiovascular events
As soon as the diagnosis of unstable angina or NSTEMI is made, and aspirin and antithrombin
therapy have been offered, formally assess individual risk of future adverse cardiovascular
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events using an established risk scoring system that predicts 6-month mortality (for example,
GRACE).
Include in the formal risk assessment:
a full clinical history (including age, previous myocardial infarction and previous PCI or
CABG)
a physical examination (including measurement of blood pressure and heart rate)
resting 12-lead ECG (looking particularly for dynamic or unstable patterns that indicatemyocardial ischaemia)
blood tests (such as troponin I or T, creatinine, glucose and haemoglobin).
Record the results of the risk assessment in the patient's care record.
Use risk assessment to guide clinical management, and balance the benefit of a treatment
against any risk of related adverse events in the light of this assessment.
Use predicted 6-month mortality to categorise the risk of future adverse cardiovascular events
as follows:
Predicted 6-month mortality Risk of future adverse cardiovascular events
1.5% or below Lowest
>1.5 to 3.0% Low
>3.0 to 6.0% Intermediate
>6.0 to 9.0% High
over 9.0% Highest
Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
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Acute coronary syndromes (including myocardial infarction)
2. Risk assessment for adults with NSTEMI or unstable angina
5 Further drug treatment for people at low risk
Clopidogrel
As soon as the risk of adverse cardiovascular events has been assessed, offer a loading dose
of 300 mg clopidogrel in addition to aspirin to patients with a predicted 6-month mortality of
more than 1.5% and no contraindications (for example, an excessive bleeding risk).
Offer a 300-mg loading dose of clopidogrel to all patients with no contraindications who may
undergo PCI within 24 hours of admission to hospital.1
Offer clopidogrel as a treatment option for up to 12 months to people who have had an NSTEMI,
regardless of treatment.
Consider discontinuing clopidogrel treatment 5 days before CABG in patients who have a low
risk of adverse cardiovascular events.
For further information on drugs for secondary prevention, see NICE's recommendations on
antiplatelets and anticoagulants in myocardial infarction: rehabilitation and preventing further
cardiovascular disease.
6 Further drug treatment for people at intermediate, high or highest risk
Clopidogrel
As soon as the risk of adverse cardiovascular events has been assessed, offer a loading dose
of 300 mg clopidogrel in addition to aspirin to patients with a predicted 6-month mortality of
more than 1.5% and no contraindications (for example, an excessive bleeding risk).
Offer a 300-mg loading dose of clopidogrel to all patients with no contraindications who may
undergo PCI within 24 hours of admission to hospital.2
Offer clopidogrel as a treatment option for up to 12 months to people who have had an NSTEMI,
regardless of treatment.
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1 There is emerging evidence about the use of a 600-mg loading dose of clopidogrel for patients undergoing PCI
within 24 hours of admission. At the time this guidance was created (July 2013), clopidogrel did not have UK
marketing authorisation for use at doses above 300 mg. The Guideline Development Group was not able to
formally review all the evidence for a 600-mg loading dose and was therefore not able to recommend this at the
time of publication of NICE clinical guideline 94 (March 2010).2 There is emerging evidence about the use of a 600-mg loading dose of clopidogrel for patients undergoing PCI
within 24 hours of admission. At the time this interactive flowchart was created (July 2013), clopidogrel did not have
UK marketing authorisation for use at doses above 300 mg. The Guideline Development Group was not able to
formally review all the evidence for a 600-mg loading dose and was therefore not able to recommend this at the
time of publication of NICE clinical guideline 94 (March 2010).
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For further information on drugs for secondary prevention, see NICE's recommendations on
antiplatelets and anticoagulants in myocardial infarction: rehabilitation and preventing further
cardiovascular disease.
Glycoprotein inhibitors
Consider intravenous eptifibatide or tirofiban1 as part of the early management for patients who
have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month
mortality above 3.0%), and who are scheduled to undergo angiography within 96 hours of
hospital admission.
Balance the potential reduction in a patient's ischaemic risk with any increased risk of bleeding,
when determining whether a glycoprotein inhibitor should be offered.
7 When to offer coronary angiography
Low risk of adverse cardiovascular events
?Offer conservative management without early coronary angiography to patients with a low risk
of adverse cardiovascular events (predicted 6-month mortality 3.0% or less).
Offer coronary angiography (with follow-on PCI if indicated) to patients initially assessed to be at
low risk of adverse cardiovascular events (predicted 6-month mortality 3.0% or less) if
ischaemia is subsequently experienced or is demonstrated by ischaemia testing.
Intermediate or higher risk of adverse cardiovascular events
Offer coronary angiography (with follow-on PCI if indicated) within 96 hours of first admission to
hospital to patients who have an intermediate or higher risk of adverse cardiovascular events
(predicted 6-month mortality above 3.0%) if they have no contraindications to angiography
(such as active bleeding or comorbidity). Perform angiography as soon as possible for patients
who are clinically unstable or at high ischaemic risk.
As an alternative to the combination of a heparin plus a glycoprotein inhibitor, consider
bivalirudin for patients who:
are at intermediate or higher risk of adverse cardiovascular events (predicted 6-monthmortality above 3%), and
are not already receiving a glycoprotein inhibitor or fondaparinux, and
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1 Eptifibatide and tirofiban are licensed for use with aspirin and unfractionated heparin. They do not have UK
marketing authorisation for use with clopidogrel. This recommendation is therefore for an off-label use of these
drugs. Informed consent should be obtained and documented before they are used in combination with clopidogrel.
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are scheduled to undergo angiography (with follow-on PCI if indicated) within 24 hours ofadmission.
New generation cardiac CT scanners
The following recommendation is an extract from NICE diagnostics guidance on new generation
cardiac CT scanners (Aquilion ONE, Brilliance iCT, Discovery CT750 HD and Somatom
Definition Flash) for cardiac imaging in people with suspected or known coronary artery disease
in whom imaging is difficult with earlier generation CT scanners.
New generation cardiac CT scanners (Aquilion ONE, Brilliance iCT, Discovery CT750 HD and
Somatom Definition Flash) are recommended as an option for first-line evaluation of disease
progression, to establish the need for revascularisation, in people with known coronary artery
disease in whom imaging with earlier generation CT scanners is difficult. CT scanning might not
be necessary in situations in which immediate revascularisation is being considered.
Fractional flow reserve measurement
NICE has published a medtech innovation briefing on the PressureWire fractional flow reserve
measurement system for coronary artery disease.
Thrombin injections for pseudoaneurysms
NICE has published interventional procedures guidance on thrombin injections for
pseudoaneurysms with normal arrangements for consent, audit and clinical governance.
Quality standards
The following quality statements are relevant to this part of the interactive flowchart.
Acute coronary syndromes (including myocardial infarction)
3. Coronary angiography and PCI within 72 hours for NSTEMI or unstable angina
4. Coronary angiography and PCI for adults with NSTEMI or unstable angina who are
clinically unstable
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8 Deciding about revascularisation
When advising patients about the choice of revascularisation strategy (PCI or CABG), take
account of coronary angiographic findings, comorbidities, and the benefits and risks of each
intervention.
When the role of revascularisation or the revascularisation strategy is unclear, resolve this by
discussion involving an interventional cardiologist, cardiac surgeon and other healthcare
professionals relevant to the needs of the patient. Discuss the choice of revascularisation
strategy with the patient.
9 Coronary artery bypass grafting
Consider discontinuing clopidogrel treatment 5 days before CABG in patients who have a low
risk of adverse cardiovascular events.
For patients at intermediate or higher risk of adverse cardiovascular events, discuss the
continuation of clopidogrel before CABG with the cardiac surgeon and base the decision on the
balance of ischaemic and bleeding risk.
MiraQ for assessing graft flow during coronary artery bypass graft surgery
The following recommendations are from NICE medical technologies guidance on MiraQ for
assessing graft flow during coronary artery bypass graft surgery.
The case for adopting the MiraQ system in the NHS for assessing graft flow during CABG
surgery is supported by the evidence. The evidence suggests that intraoperative transit time
flow measurement is effective in detecting imperfections that may be corrected by graft revision.
This may reduce the incidence of graft occlusion and may reduce perioperative morbidity and
mortality.
The MiraQ system is associated with an estimated cost saving of £141 per patient compared
with clinical assessment, when it is used routinely for assessing coronary artery bypass grafts
during surgery.
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Detecting, managing and monitoring haemostasis: viscoelastometric point-of-caretesting
The following recommendations are an extract from NICE diagnostics guidance on detecting,
managing and monitoring haemostasis: viscoelastometric point-of-care testing (ROTEM, TEG
and Sonoclot systems).
The ROTEM system and the TEG system are recommended to help detect, manage and
monitor haemostasis during and after cardiac surgery.
The Sonoclot system is only recommended for use in research to help detect, manage and
monitor haemostasis during and after cardiac surgery. Research is recommended into the
clinical benefits and cost effectiveness of using the Sonoclot system during and after cardiac
surgery (see section 7.1 of the guidance).
Healthcare professionals using the ROTEM system and the TEG system during cardiac surgery
should have appropriate training and experience with these devices.
'Depth of anaesthesia' monitors
The following recommendations are from NICE diagnostics guidance on depth of anaesthesia
monitors.
The use of EEG-based depth of anaesthesia monitors is recommended as an option during any
type of general anaesthesia in patients considered at higher risk of adverse outcomes. This
includes patients at higher risk of unintended awareness and patients at higher risk of
excessively deep anaesthesia. The BIS depth of anaesthesia monitor is therefore
recommended as an option in these patients.
The use of EEG-based depth of anaesthesia monitors is also recommended as an option in all
patients receiving total intravenous anaesthesia. The BIS monitor is therefore recommended as
an option in these patients.
Although there is greater uncertainty of clinical benefit for the E-Entropy and Narcotrend-
Compact M depth of anaesthesia monitors than for the BIS monitor, the Committee concluded
that the E-Entropy and Narcotrend-Compact M monitors are broadly equivalent to BIS. These
monitors are therefore recommended as options during any type of general anaesthesia in
patients considered at higher risk of adverse outcomes. This includes patients at higher risk of
unintended awareness and patients at higher risk of excessively deep anaesthesia. The E-
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Entropy and Narcotrend-Compact M monitors are also recommended as options in patients
receiving total intravenous anaesthesia.
Anaesthetists using EEG-based depth of anaesthesia monitors should have appropriate training
and experience with these monitors and understand the potential limitations of their use in
clinical practice.
NICE has published a medtech innovation briefing on End-tidal Control software for use with
Aisys closed circuit anaesthesia systems for automated gas control during general anaesthesia.
CardioQ-ODM oesophageal doppler monitor
The following recommendations are from NICE medical technologies guidance on CardioQ-
ODM oesophageal doppler monitor.
The case for adopting the CardioQ-ODM in the NHS, when used as described below, is
supported by the evidence. There is a reduction in post-operative complications, use of central
venous catheters and in-hospital stay (with no increase in the rate of re-admission or repeat
surgery) compared with conventional clinical assessment with or without invasive cardiovascular
monitoring. The cost saving per patient, when the CardioQ-ODM is used instead of a central
venous catheter in the peri-operative period, is about £1100 based on a 7.5-day hospital stay.
The CardioQ-ODM should be considered for use in patients undergoing major or high-risk
surgery or other surgical patients in whom a clinician would consider using invasive
cardiovascular monitoring.
Interventional procedures
NICE has published guidance on the following procedures with normal arrangements for
clinical governance, consent and audit:
endoscopic saphenous vein harvest for coronary artery bypass grafting
off-pump coronary artery bypass grafting
endoaortic balloon occlusion for cardiac surgery.
NICE has published guidance on totally endoscopic robotically assisted coronary artery bypass
grafting with special arrangements for consent and audit or research.
NICE has published guidance on intraoperative fluorescence angiography in coronary artery
bypass grafting (see guidance for details).
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Medtech innovation briefings
NICE has published medtech innovation briefings on:
PleuraFlow Active Clearance Technology for maintaining chest tube patency
VEST external stent for coronary artery bypass grafts
Sternal Talon for sternal closure in cardiothoracic surgery.
10 Percutaneous coronary intervention
Consider abciximab as an adjunct to PCI for patients at intermediate or higher risk of adverse
cardiovascular events who are not already receiving a glycoprotein inhibitor.
Offer systemic unfractionated heparin (50–100 units/kg) in the cardiac catheter laboratory to
patients receiving fondaparinux who are undergoing PCI1.
As an alternative to the combination of a heparin plus a glycoprotein inhibitor, consider
bivalirudin for patients undergoing PCI who:
are at intermediate or higher risk of adverse cardiovascular events, and
are not already receiving a glycoprotein inhibitor or fondaparinux.
NICE has published a medtech innovation briefing on ClearWay RX for drug delivery to
coronary artery thrombotic lesions.
Prasugrel
The following recommendation is from NICE technology appraisal guidance on prasugrel with
percutaneous coronary intervention for treating acute coronary syndromes.
Prasugrel 10 mg in combination with aspirin is recommended as an option within its marketing
authorisation, that is, for preventing atherothrombotic events in adults with acute coronary
syndrome (unstable angina, NSTEMI or STEMI) having primary or delayed PCI.
NICE has written information for the public on prasugrel.
Cangrelor
The NICE technology appraisal of cangrelor for reducing atherothrombotic events in people
undergoing percutaneous coronary intervention or awaiting surgery requiring interruption of anti-
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1 At the time this guidance was created (July 2013), unfractionated heparin did not have a marketing authorisation
for use during angiography and PCI. Such use is an off-label use. Informed consent should be obtained and
documented before it is used during angiography and PCI.
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platelet therapy was terminated because no evidence submission was received from The
Medicines Company for the technology. Therefore NICE is unable to make a recommendation
about the use in the NHS of cangrelor for reducing atherothrombotic events in people
undergoing PCI or awaiting surgery requiring interruption of anti-platelet therapy.
NICE has published an evidence summary on coronary revascularisation: cangrelor.
Glycoprotein inhibitors
The following recommendations are from NICE technology appraisal guidance on the use of
glycoprotein IIb/IIIa inhibitors in the treatment of acute coronary syndromes.
It is recommended that a glycoprotein IIb/IIIa inhibitor is considered as an adjunct to PCI for all
patients with diabetes undergoing elective PCI, and for those patients undergoing complex
procedures (for example, multi-vessel PCI, insertion of multiple stents, vein graft PCI or PCI for
bifurcation lesions); currently only abciximab is licensed as an adjunct to PCI. In procedurally
uncomplicated, elective PCI, where the risk of adverse sequelae is low, use of a glycoprotein
IIb/IIIa inhibitor is not recommended unless unexpected immediate complications occur.
Glycoprotein IIb/IIIa inhibitors are not currently licensed in the UK for use as an adjunct to
thrombolytic therapy in STEMI.
NICE has written information for the public on glycoprotein inhibitors.
Coronary artery stents
The following recommendations are from NICE technology appraisal guidance on the use of
coronary artery stents.
Stents should be used routinely where PCI is the clinically appropriate procedure for patients
with either stable or unstable angina or with acute myocardial infarction.
This guidance specifically relates to the present clinical indications for PCI and excludes
conditions (such as many cases of stable angina) that are adequately managed with standard
drug therapy.
NICE has written information for the public on coronary artery stents.
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Drug-eluting stents
The following recommendation is from NICE technology appraisal guidance on drug-eluting
stents for the treatment of coronary artery disease.
Drug-eluting stents are recommended for use in PCI for the treatment of coronary artery
disease, within their instructions for use, only if:
the target artery to be treated has less than a 3-mm calibre or the lesion is longer than 15mm, and
the price difference between drug-eluting stents and bare-metal stents is no more than£300.
NICE has written information for the public on drug-eluting stents.
Bioresorbable stents
NICE has published interventional procedures guidance on bioresorbable stent implantation for
treating coronary artery disease with special arrangements for clinical governance, consent
and audit or research.
Interventional procedures
NICE has published guidance on:
optical coherence tomography to guide percutaneous coronary intervention with specialarrangements for consent, audit and clinical governance
percutaneous laser coronary angioplasty with normal arrangements for clinicalgovernance, consent and audit
thrombin injections for pseudoaneurysms with normal arrangements for consent, auditand clinical governance.
Medtech innovation briefings
NICE has published medtech innovation briefings on:
Impella 2.5 for haemodynamic support during high-risk percutaneous coronary interventions
the PressureWire fractional flow reserve measurement system for coronary artery disease.
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People who have previously had PCI
SeQuent Please balloon catheter for in-stent coronary restenosis
The following recommendations are from NICE medical technologies guidance on SeQuent
Please balloon catheter for in-stent coronary restenosis.
The case for adopting SeQuent Please balloon catheter in the NHS, when used as described
below, is supported by the evidence. The need for subsequent re-intervention for coronary
stenosis is reduced as is the duration of clopidogrel therapy, compared with paclitaxel-eluting
stent. SeQuent Please balloon catheter is associated with a cost saving of £467 per patient
compared with paclitaxel-eluting stent.
SeQuent Please balloon catheter should be considered for use in patients with in-stent
restenosis in bare metal coronary artery stents.
SeQuent Please balloon catheter can also be considered as an option for patients with in-stent
restenosis in any type of coronary artery stent if:
there are clinical reasons to minimise the duration of clopidogrel treatment (for example,there is concern about an increased risk of bleeding or there is the need for surgicalintervention) or
placement of further stents is not technically possible.
Further research is recommended in a UK setting to compare the outcomes of patients treated
with SeQuent Please balloon catheter with the outcomes of patients treated with other types of
drug-eluting balloon catheter and stent. This research should report long-term outcomes (for
example, after 3 years), including clinical outcomes and details of further revascularisation
required for subsequent restenosis. Research should investigate the use of SeQuent Please
balloon catheter for restenosis in drug-eluting coronary artery stents and in de novo coronary
stenosis where stenting is either technically difficult or is associated with an increased risk of
complications. If research shows that SeQuent Please balloon catheter reduces the rate of
restenosis in patients with drug-eluting stents or in native coronary arteries, compared with
other technologies, then the number of patients for whom it might be suitable would increase
significantly.
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11 Discharge planning and cardiac rehabilitation
To detect and quantify inducible ischaemia, consider ischaemia testing before discharge for
patients whose condition has been managed conservatively and who have not had coronary
angiography.
Before discharge offer patients advice and information about:
their diagnosis and arrangements for follow-up (in line with NICE's recommendations onmyocardial infarction: rehabilitation and preventing further cardiovascular disease)
cardiac rehabilitation (in line with NICE's recommendations on myocardial infarction:rehabilitation and preventing further cardiovascular disease)
management of cardiovascular risk factors and drug therapy for secondary prevention (inline with NICE's recommendations on myocardial infarction: rehabilitation and preventingfurther cardiovascular disease and cardiovascular disease prevention)
lifestyle changes.
All patients who smoke should be advised to quit and be offered support and advice, and
referral to an intensive support service (for example, the NHS Stop Smoking Services) in line
with NICE's recommendations on stop smoking interventions and services.
Make cardiac rehabilitation equally accessible and relevant to all people after a myocardial
infarction, particularly people from groups that are less likely to access this service. These
include people from black and minority ethnic groups, older people, people from lower
socioeconomic groups, women, people from rural communities, people with a learning disability
and people with mental and physical health conditions.
12 See what NICE says on myocardial infarction: rehabilitation andpreventing further cardiovascular disease
See Myocardial infarction: rehabilitation and preventing further cardiovascular disease
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Glossary
ACE
angiotensin-converting enzyme
BIS
Bispectral Index
CABG
coronary artery bypass graft
ECG
electrocardiogram
EEG
electroencephalography
GRACE
Global Registry of Acute Coronary Events
GTN
glyceryl trinitrate
MPS with SPECT
myocardial perfusion scintigraphy with single photon emission CT
NSTEMI
non-ST-segment elevation myocardial infarction
PCI
percutaneous coronary intervention
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SPECT
single photon emission CT
STEMI
ST-segment elevation myocardial infarction
ST-T
ST-segment-T-wave
Sources
Unstable angina and NSTEMI: early management (2010) NICE guideline CG94
Cangrelor for reducing atherothrombotic events in people undergoing percutaneous coronary
intervention or awaiting surgery requiring interruption of anti-platelet therapy (terminated
appraisal) (2015) NICE technology appraisal 351
Prasugrel with percutaneous coronary intervention for treating acute coronary syndromes
(review of technology appraisal guidance 182) (2014) NICE technology appraisal guidance 317
Ticagrelor for the treatment of acute coronary syndromes (2011) NICE technology appraisal
guidance 236
Drug-eluting stents for the treatment of coronary artery disease (2008) NICE technology
appraisal guidance 152
Guidance on the use of coronary artery stents (2003) NICE technology appraisal guidance 71
Guidance on the use of glycoprotein IIb/IIIa inhibitors in the treatment of acute coronary
syndromes (2002) NICE technology appraisal guidance 47
MiraQ for assessing graft flow during coronary artery bypass graft surgery (2011 updated 2018)
NICE medical technologies guidance 8
CardioQ-ODM oesophageal doppler monitor (2011) NICE medical technologies guidance 3
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SeQuent Please balloon catheter for in-stent coronary restenosis (2010) NICE medical
technologies guidance 1
Detecting, managing and monitoring haemostasis: viscoelastometric point-of-care testing
(ROTEM, TEG and Sonoclot systems) (2014) NICE diagnostics guidance 13
Depth of anaesthesia monitors – Bispectral Index (BIS), E-Entropy and Narcotrend-Compact M
(2012) NICE diagnostics guidance 6
New generation cardiac CT scanners (Aquilion ONE, Brilliance iCT, Discovery CT750 HD and
Somatom Definition Flash) for cardiac imaging in people with suspected or known coronary
artery disease in whom imaging is difficult with earlier generation CT scanners (2012) NICE
diagnostics guidance 3
Your responsibility
Guidelines
The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual
needs, preferences and values of their patients or the people using their service. It is not
mandatory to apply the recommendations, and the guideline does not override the responsibility
to make decisions appropriate to the circumstances of the individual, in consultation with them
and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline
to be applied when individual professionals and people using services wish to use it. They
should do so in the context of local and national priorities for funding and developing services,
and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to
advance equality of opportunity and to reduce health inequalities. Nothing in this guideline
should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable
health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.
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Technology appraisals
The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, health
professionals are expected to take these recommendations fully into account, alongside the
individual needs, preferences and values of their patients. The application of the
recommendations in this interactive flowchart is at the discretion of health professionals and
their individual patients and do not override the responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable
the recommendations to be applied when individual health professionals and their patients wish
to use it, in accordance with the NHS Constitution. They should do so in light of their duties to
have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable
health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.
Medical technologies guidance, diagnostics guidance and interventional proceduresguidance
The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, healthcare
professionals are expected to take these recommendations fully into account. However, the
interactive flowchart does not override the individual responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in
their local context, in light of their duties to have due regard to the need to eliminate unlawful
discrimination, advance equality of opportunity, and foster good relations. Nothing in this
interactive flowchart should be interpreted in a way that would be inconsistent with compliance
with those duties.
Early management of unstable angina and NSTEMIEarly management of unstable angina and NSTEMI NICE Pathways
Chest painChest pain© NICE 2018. All rights reserved. Subject to Notice of rights.
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Commissioners and providers have a responsibility to promote an environmentally sustainable
health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.
Early management of unstable angina and NSTEMIEarly management of unstable angina and NSTEMI NICE Pathways
Chest painChest pain© NICE 2018. All rights reserved. Subject to Notice of rights.
Page 24 of 24