Diagnostic coronary angiography for low risk, stable chest pain
Best Practice Guidance
Summary
NICE guidelines recommend that where a diagnosis of chest pain cannot, by clinical assessment alone, exclude stable angina, 64-slice (or above) CT coronary angiography should be offered as first-line. Invasive coronary angiography should only be offered to patients with significant findings on CT coronary angiogram or with inconclusive further imaging.
This guidance applies to adults aged 19 years and over.
Recommendation
When results of non-invasive functional imaging are inconclusive and patients are assessed as having low risk, stable cardiac pain, invasive coronary angiography (cardiac catheterisation) should be offered only as third-line investigation.
Patients who have chest pain that is not an Acute Coronary Syndrome (ACS), but there is concern that it is due to an ischemic cause (stable angina) should, in the first instance, be offered a CT Coronary angiography (64 slice or above). This is based on:
- Clinical assessment indicating typical or atypical angina; or
- Clinical assessment indicates non-anginal chest pain but the 12‑lead resting ECG shows ST‑T changes or Q waves.
Significant coronary artery disease (CAD) found during CT coronary angiography is ≥ 70% diameter stenosis of at least one major epicardial artery segment or ≥ 50% diameter stenosis in the left main coronary artery.
If the CT coronary angiography is inconclusive, non-invasive functional imaging for myocardial ischemia should be considered in the following forms:
- Stress echocardiography; or
- First-pass contrast-enhanced magnetic resonance (MR) stress perfusion; or
- MR imaging for stress-induced wall motion abnormalities; or
- Fractional flow reserve CT (FFR-CT); or
- Myocardial perfusion scintigraphy with single photon emission computed tomography (MPS with SPECT).
Invasive coronary angiography should only be offered as third-line investigation when the results of non-invasive functional imaging are inconclusive.
Rationale for recommendation
NICE guidelines recommend that where a diagnosis of chest pain cannot, by clinical assessment alone, exclude stable angina, 64-slice (or above) CT coronary angiography should be offered as first-line investigation. Cardiac catheterisation and coronary angiography are generally considered to be safe procedures. However, as with all medical procedures, there are some associated risks. The main risks of coronary angiography include:
- Haematoma or bruising in groin or arm
- Allergy to the contrast
- A very small risk including damage to the artery in the arm or leg where the catheter was inserted, heart attack, stroke, kidney damage and, very rarely, death (risk of a serious complication occurring is estimated to be less than 1 in 1,000. People with serious underlying heart problems are most at risk.)
Patient information
There is no specific EBI patient guidance for this intervention.
However, we recommend using the BRAN principles (Benfits, Risks, Alternatives and do Nothing) when speaking with patients about this.
Further information on patient involvement in EBI can be found on the EBI for patients section.
Coding
Code Script
WHEN LEFT(der.Spell_Dominant_Procedure,4) like '%K63[12345689]%' AND not (apcs.der_diagnosis_all like '%I20[018]%' OR apcs.der_diagnosis_all like '%I21[012349]%’ OR apcs.der_diagnosis_all like '%I2[24][0189]%’ OR apcs.der_diagnosis_all like '%I23[01234568]%’ OR apcs.der_diagnosis_all like '%I25[012345689]%') AND not (apcs.Der_Procedure_All like '%U10[1-9]%’ OR apcs.Der_Procedure_All like '%U205%’ OR apcs.Der_Procedure_All like '%U115%’) AND isnull(APCS.Age_At_Start_of_Spell_SUS,APCS.Der_Age_at_CDS_Activity_Date) between 19 and 120 THEN '2A_Angio'
Code Definitions
Procedure codes (OPCS)
Main
K631 Angiocardiography of combination of right and left side of heart
K632 Angiocardiography of right side of heart NEC
K633 Angiocardiography of left side of heart NEC
K634 Coronary arteriography using two catheters
K635 Coronary arteriography using single catheter
K636 Coronary arteriography NEC
K638 Other specified contrast radiology of heart
K639 Unspecified contrast radiology of heart
Exclusion
U205 Stress echocardiography
U106 Myocardial perfusion scan
U115 Thallium stress test
U101 Cardiac computed tomography for calcium scoring
U102 Cardiac computed tomography angiography
U103 Cardiac magnetic resonance imaging
U104 Myocardial positron emission tomography
U105 Radionuclide angiocardiography
U106 Myocardial perfusion scan
U107 Cardiac multiple gated acquisition scan
U108 Other specified diagnostic imaging of heart
U109 Unspecified diagnostic imaging of heart
U115 Thallium stress test
Diagnosis codes (ICD)
Exclusion
I200 Unstable angina
I201 Angina pectoris with documented spasm
I208 Other forms of angina pectoris
I210 Acute transmural myocardial infarction of anterior wall
I211 Acute transmural myocardial infarction of inferior wall
I212 Acute transmural myocardial infarction of other sites
I213 Acute transmural myocardial infarction of unspecified site
I214 Acute subendocardial myocardial infarction
I219 Acute myocardial infarction, unspecified
I220 Subsequent myocardial infarction of anterior wall
I221 Subsequent myocardial infarction of inferior wall
I228 Subsequent myocardial infarction of other sites
I229 Subsequent myocardial infarction of unspecified site
I230 Haemopericardium as current complication following acute myocardial infarction
I231 Atrial septal defect as current complication following acute myocardial infarction
I232 Ventricular septal defect as current complication following acute myocardial infarction
I233 Rupture of cardiac wall without haemopericardium as current complication following acute myocardial infarction
I234 Rupture of chordae tendineae as current complication following acute myocardial infarction
I235 Rupture of papillary muscle as current complication following acute myocardial infarction
I236 Thrombosis of atrium, auricular appendage, and ventricle as current complications following acute myocardial infarction
I238 Other current complications following acute myocardial infarction
I240 Coronary thrombosis not resulting in myocardial infarction
I241 Dressler syndrome
I248 Other forms of acute ischaemic heart disease
I249 Acute ischaemic heart disease, unspecified
I250 Atherosclerotic cardiovascular disease, so described
I251 Atherosclerotic heart disease
I252 Old myocardial infarction
I253 Aneurysm of heart
I254 Coronary artery aneurysm and dissection
I255 Ischaemic cardiomyopathy
I256 Silent myocardial ischaemia
I258 Other forms of chronic ischaemic heart disease
I259 Chronic ischaemic heart disease, unspecified
Additional Exclusions
apcs.der_diagnosis_all not like '%C[0-9][0-9]%' and apcs.der_diagnosis_all not like '%D0%' and apcs.der_diagnosis_all not like '%D3[789]%' and apcs.der_diagnosis_all not like '%D4[012345678]%’
This code captures code in the ranges C00-C99, D00-D09 and D37-D48.
Age range: the codes use the following age ranges 0-18 for children and 19-120
for adults.
— Private Appointment Exclusion
AND apcs.Administrative_Category<>’02’
References
- Clinical guidance (2010) Chest pain of recent onset: assessment and diagnosis (clinical guideline [CG95]
- NICE Resource (2016) Resource impact report: Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis (CG95)
- NHS advice: https://www.nhs.uk/conditions/coronary-angiography/
- NHS advice: https://www.nhs.uk/conditions/coronary-angiography/risks/
- NICE. Medical technologies guidance (2017) HeartFlow FFRCT for estimating fractional flow reserve from coronary CT angiography [MTG32].
How up to date is this information?
Last revised December 2023
Changes
December 2023 - Coding updated. August 2022 - Coding updated
