Early management of unstable angina and NSTEMI management of unstable angina and NSTEMI NICE Pathways bring together everything NICE says on a topic in an interactive flowchart. NICE

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.

Chest painChest pain© NICE 2018. All rights reserved. Subject to Notice of rights.

Page 1 of 24

http://pathways.nice.org.uk/pathways/chest-pain

http://www.nice.org.uk/

https://www.nice.org.uk/terms-and-conditions#notice-of-rights

Early management of unstable angina and NSTEMIEarly management of unstable angina and NSTEMI NICE Pathways


Page 2 of 24


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:



Page 3 of 24

http://www.nice.org.uk/guidance/CG94/informationforpublic

http://www.nice.org.uk/guidance/CG94/informationforpublic


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



Page 4 of 24

http://www.nice.org.uk/guidance/TA236

http://www.nice.org.uk/guidance/TA236/InformationForPublic

http://pathways.nice.org.uk/pathways/medicines-optimisation


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.



Page 5 of 24


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.



Page 6 of 24

http://pathways.nice.org.uk/pathways/myocardial-infarction-rehabilitation-and-preventing-further-cardiovascular-disease/drug-treatment-after-myocardial-infarction#content=view-node%3Anodes-antiplatelets-and-anticoagulants


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).


Page 7 of 24


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



Page 8 of 24

http://pathways.nice.org.uk/pathways/myocardial-infarction-rehabilitation-and-preventing-further-cardiovascular-disease/drug-treatment-after-myocardial-infarction#content=view-node%3Anodes-antiplatelets-and-anticoagulants


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.


Page 9 of 24


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



Page 10 of 24

http://www.nice.org.uk/guidance/DG3




http://www.nice.org.uk/advice/MIB2


http://www.nice.org.uk/guidance/IPG60



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.



Page 11 of 24

http://www.nice.org.uk/guidance/MTG8



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-



Page 12 of 24

http://www.nice.org.uk/guidance/dg13



http://www.nice.org.uk/guidance/dg13/chapter/7-Recommendations-for-further-research




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).



Page 13 of 24



http://www.nice.org.uk/guidance/mtg3

http://www.nice.org.uk/guidance/mtg3









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-



Page 14 of 24












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.


Page 15 of 24


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.



Page 16 of 24


http://www.nice.org.uk/guidance/ESNM63








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.



Page 17 of 24












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.



Page 18 of 24




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



Page 19 of 24

http://pathways.nice.org.uk/pathways/myocardial-infarction-rehabilitation-and-preventing-further-cardiovascular-disease





http://pathways.nice.org.uk/pathways/cardiovascular-disease-prevention

http://smokefree.nhs.uk/

http://pathways.nice.org.uk/pathways/smoking/stop-smoking-interventions-and-services



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



Page 20 of 24


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



Page 21 of 24

http://www.nice.org.uk/guidance/CG94














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.



Page 22 of 24








https://www.nice.org.uk/about/who-we-are/sustainability



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.




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.



Page 23 of 24









Page 24 of 24




Documents

Early management of unstable angina and NSTEMI management of unstable angina and NSTEMI NICE Pathways bring together everything NICE says on a topic in an interactive flowchart. NICE