The National Institute for Health and Care Excellence update for stable chest pain: poorly reasoned and risky for patients

For nearly two decades, the National Institute for Health and Care Excellence (NICE) has been admired as a reliable and authoritative source for evidence-based practice pathways. Unfortunately, in the latest iteration of the stable chest pain guidelines, NICE has veered dangerously off course by advocating that we abandon Bayesian analysis and simply order CT  coronary angiography (CTCA) in all patients with typical or atypical chest pain.1 The clinician should no longer consider a patient’s pretest probability, whether any imaging is necessary, and if so, which imaging test is best. These recommendations are not supported by high quality scientific evidence and put patients at risk for serious harm. At its foundation, the NICE guideline is antithetical to the current focus on a more personalised approach to medicine with conscientious use of diagnostic imaging, particularly when it involves ionising radiation. Moreover, given that cardiovascular events have dramatically decreased with improved risk factor modification,2 why should we advocate for more imaging and radiation exposure in patients at increasingly lower risk? To support their radical changes to the diagnostic paradigm, the authors make several erroneous assertions. First, they contend that an assessment of the pretest probability of coronary artery disease (CAD) is useless and that exercise testing should not be performed given its limited diagnostic performance and the absence of prognostic value. In addition, they incorrectly assert that CTCA is more cost-effective and that trials of CTCA have consistently demonstrated its superiority. Given the implications, these assertions warrant critical appraisal (table 1). View this table: Table 1 Summary of arguments in support of and in opposition to the updated NICE stable chest pain guidelines In their classic work,3 Diamond and Forrester stated that ‘the data presented… should not be considered as absolute standards but, rather, as …