NICE 2020
Other
Noted
NICE acknowledges the concerns and notes that existing guidance (CG95) flags points where healthcare professionals should consider aortic dissection. They note that topic experts decided against including more detailed guidance, but that they will engage with professional bodies to improve use of their guidelines. (AI summary)
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Dear Mr Farrow,
I write in response to your Regulation 28 Report, dated 4 September 2020, regarding the tragic death of Zoe Amanda Knight.
We have considered the circumstances surrounding Ms Knight’s death and the matters of concern raised in your report, including concerns about awareness of aortic dissection and implementation of recommendations on this topic.
NICE guidance relevant to aortic dissection
NICE has published a guideline on recent-onset chest pain of suspected cardiac origin: assessment and diagnosis (CG95). Several recommendations in this guideline flag various points at which healthcare professionals should consider the possibility that a person presenting with recent onset chest pain of suspected cardiac origin may have aortic dissection:
• Recommendation 1.2.1.13 advises that, if an acute coronary syndrome (ACS) is not suspected, other causes of chest pain be considered, some of which may be life-threatening.
• Recommendation 1.2.2.8 says that if clinical assessment and a resting 12-lead ECG make a diagnosis of ACS less likely to consider other acute conditions, specifically citing aortic dissection as an example.
• Recommendation 1.2.4.2 states that a physical examination should be carried out to determine factors including signs of non-coronary causes of acute chest pain, such as aortic dissection.
• Recommendation 1.2.6.2 advises that, when a raised troponin level is observed in people with suspected ACS, that other causes for raised
troponins be considered, specifically citing aortic dissection as an example.
• Recommendation 1.2.6.7 states that early chest CT only be considered to rule out other diagnoses, again specifically citing aortic dissection as an example.
Reviewing this guideline
This guideline underwent a surveillance review in 2019, to determine whether any new evidence indicated that it needed to be updated. Ultimately, no additional evidence was identified with potential impact on these existing recommendations.
During this review, NICE also considered whether more detailed guidance on the diagnosis of aortic dissection (or acute aortic syndrome) should be included in the guideline.
Topic experts were consulted on this issue, including experts in emergency medicine. While intelligence was considered relating to the inclusion of further guidance on the diagnosis of aortic dissection , the majority view was that this would not be appropriate. The decision was therefore made that the guideline would not be updated in this regard. During the surveillance review process, it was noted that there are several existing non-NICE guidelines and educational resources for acute aortic syndrome.
Encouraging best practice
In terms of improving awareness and learning on this topic, the responsibility for the education and training of healthcare professionals rests with the relevant professional bodies, such as the Royal Colleges, the GMC and Health Education England. We regularly engage with these organisations to improve use of our guidelines, and we will follow up in relation to this issue.
To help support the implementation of our guideline CG95, a range of externally- produced resources can be accessed from the tools and resources section of our website.
I do hope this response indicates that we have investigated this issue thoroughly, and will work with partners to encourage a change in practice.
I write in response to your Regulation 28 Report, dated 4 September 2020, regarding the tragic death of Zoe Amanda Knight.
We have considered the circumstances surrounding Ms Knight’s death and the matters of concern raised in your report, including concerns about awareness of aortic dissection and implementation of recommendations on this topic.
NICE guidance relevant to aortic dissection
NICE has published a guideline on recent-onset chest pain of suspected cardiac origin: assessment and diagnosis (CG95). Several recommendations in this guideline flag various points at which healthcare professionals should consider the possibility that a person presenting with recent onset chest pain of suspected cardiac origin may have aortic dissection:
• Recommendation 1.2.1.13 advises that, if an acute coronary syndrome (ACS) is not suspected, other causes of chest pain be considered, some of which may be life-threatening.
• Recommendation 1.2.2.8 says that if clinical assessment and a resting 12-lead ECG make a diagnosis of ACS less likely to consider other acute conditions, specifically citing aortic dissection as an example.
• Recommendation 1.2.4.2 states that a physical examination should be carried out to determine factors including signs of non-coronary causes of acute chest pain, such as aortic dissection.
• Recommendation 1.2.6.2 advises that, when a raised troponin level is observed in people with suspected ACS, that other causes for raised
troponins be considered, specifically citing aortic dissection as an example.
• Recommendation 1.2.6.7 states that early chest CT only be considered to rule out other diagnoses, again specifically citing aortic dissection as an example.
Reviewing this guideline
This guideline underwent a surveillance review in 2019, to determine whether any new evidence indicated that it needed to be updated. Ultimately, no additional evidence was identified with potential impact on these existing recommendations.
During this review, NICE also considered whether more detailed guidance on the diagnosis of aortic dissection (or acute aortic syndrome) should be included in the guideline.
Topic experts were consulted on this issue, including experts in emergency medicine. While intelligence was considered relating to the inclusion of further guidance on the diagnosis of aortic dissection , the majority view was that this would not be appropriate. The decision was therefore made that the guideline would not be updated in this regard. During the surveillance review process, it was noted that there are several existing non-NICE guidelines and educational resources for acute aortic syndrome.
Encouraging best practice
In terms of improving awareness and learning on this topic, the responsibility for the education and training of healthcare professionals rests with the relevant professional bodies, such as the Royal Colleges, the GMC and Health Education England. We regularly engage with these organisations to improve use of our guidelines, and we will follow up in relation to this issue.
To help support the implementation of our guideline CG95, a range of externally- produced resources can be accessed from the tools and resources section of our website.
I do hope this response indicates that we have investigated this issue thoroughly, and will work with partners to encourage a change in practice.