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In March 2010, the National Institute for Health and Clinical Excellence (NICE) published evidence-based recommendations on best practice in the assessment and diagnosis of patients with chest pain that may be of cardiac origin.1 For those with suspected ‘stable angina’, they recommend initial clinical risk assessment to estimate the likelihood of coronary artery disease following which the requirement for diagnostic testing (anatomical testing for obstructive coronary artery disease and/or functional testing for myocardial ischaemia) is ascertained. As such, the guideline aims to provide objective clinical criteria for determining whether diagnostic testing is necessary and if so what test should be used. One of the most controversial decisions in the guidance is the omission of exercise tolerance testing from the diagnostic algorithm. Instead, advanced cardiac imaging modalities feature heavily, including cardiac multi-detector CT (MDCT), nuclear perfusion scintigraphy, stress echocardiography and perfusion cardiac MRI. These are highly specialised and resource-intensive investigations, which not all hospitals will have direct access to, especially in the district general hospital …
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