NICE vs RCP: Management of Stable Angina (2025)

This guide provides a comparative overview of the key recommendations for the management of stable angina in adults, as set out by the National Institute for Health and Care Excellence (NICE) Clinical Guideline CG126 (last updated July 2023) and the Royal College of Physicians (RCP) London Clinical Guideline on Stable Chest Pain (2023). It is intended for clinicians in the UK to understand the nuances, similarities, and differences between these two influential guidelines to inform daily practice.

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Diagnosis and Assessment

The initial assessment of a patient presenting with suspected stable angina is a critical first step. Both guidelines emphasise the importance of clinical history and risk stratification, but they diverge significantly on the recommended diagnostic pathways for confirming coronary artery disease (CAD).

NICE CG126 Approach

NICE advocates for the use of Coronary Computed Tomography Angiography (CCTA) as the first-line diagnostic test for all patients in whom stable angina is suspected, regardless of their pre-test probability. This is a major shift from previous functional testing paradigms.

• First-line Test: CCTA for all patients with suspected stable angina.
• Rationale: High sensitivity for ruling out significant CAD, providing direct anatomical information.
• If CCTA is contraindicated or unavailable: NICE suggests functional imaging (e.g., cardiac MRI perfusion, myocardial perfusion scintigraphy) or stress echocardiography.
• Invasive Coronary Angiography (ICA): Primarily reserved for patients where revascularisation is being considered based on non-invasive test results, or when non-invasive tests are inconclusive.

RCP London Approach

The RCP guideline takes a more traditional, pre-test probability (PTP)-driven approach, aligning more closely with European Society of Cardiology (ESC) guidelines.

• Pre-test Probability (PTP): The choice of test is determined by the patient's estimated PTP of CAD.
• Low PTP (<10%): Investigation for alternative causes of chest pain is recommended.
• Intermediate PTP (10-90%): Functional testing is the first-line investigation (e.g., CTCA, stress ECG, functional imaging). The choice depends on local expertise and availability.
• High PTP (>90%): Consider direct referral to Invasive Coronary Angiography (ICA), as the likelihood of disease is so high that a non-invasive test may be redundant.

Key Difference: The most significant divergence is the first-line diagnostic test. NICE mandates CCTA for nearly all patients, while the RCP uses a risk-stratified approach where functional testing remains a core option. This has major implications for NHS imaging departments and referral pathways.

Pharmacological Management

Both guidelines agree on the core principles of pharmacological therapy: to relieve symptoms and prevent cardiovascular events. The recommendations for first- and second-line agents are largely consistent.

First-line Therapy

• Both NICE and RCP: Recommend a beta-blocker or calcium channel blocker (CCB) as first-line anti-anginal therapy. The choice should be individualised based on comorbidities, contraindications, and patient preference.

Second-line and Additional Therapy

• If symptoms persist: Both guidelines recommend combining a beta-blocker with a dihydropyridine CCB, or switching to an alternative agent.
• Other Agents: Both mention the use of long-acting nitrates, ivabradine (if heart rate control is inadequate with beta-blockers), nicorandil, and ranolazine as additional options for refractory angina.
• Secondary Prevention: Both strongly emphasise the importance of aspirin (or alternative antiplatelet if contraindicated), high-intensity statin therapy, and ACE inhibitors (if indicated for hypertension, heart failure, or diabetes).

Practical Takeaway: Pharmacological management is an area of strong consensus. The focus should be on optimal dosing of first-line agents and ensuring robust secondary prevention.

Special Situations

Microvascular Angina and Vasospastic Angina

• NICE: Provides specific recommendations, acknowledging these entities. For patients with no obstructive CAD on CCTA/ICA but with typical symptoms, further investigation for microvascular or vasospastic angina should be considered.
• RCP: Also addresses these conditions, recommending calcium channel blockers as first-line for vasospastic angina and noting the potential role of anti-anginals like ranolazine for microvascular dysfunction.
• Consensus: Both guidelines highlight the importance of recognising these diagnoses when investigations for obstructive CAD are negative.

Revascularisation (PCI/CABG)

• Both NICE and RCP: Stress that revascularisation is primarily for symptom relief and does not confer a mortality benefit over optimal medical therapy (OMT) in most patients with stable CAD.
• Indication: Revascularisation should be considered for patients whose symptoms are not adequately controlled by OMT.
• Decision-making: The choice between Percutaneous Coronary Intervention (PCI) and Coronary Artery Bypass Graft (CABG) should be made by a Heart Team, considering coronary anatomy, comorbidities, and patient choice.

Practical Clinical Flow: A Comparative Summary

NICE CG126 Flow

1. Suspected Stable Angina: Take clinical history and assess risk factors.
2. Diagnostic Test: Offer CCTA as first-line.
3. CCTA Result:
   • No CAD: Consider alternative diagnoses (e.g., microvascular angina).
   • Non-obstructive CAD: Optimise medical therapy.
   • Obstructive CAD: Optimise medical therapy. If symptoms persist, refer to a Heart Team for revascularisation discussion.

RCP London Flow

1. Suspected Stable Angina: Take clinical history and calculate Pre-test Probability (PTP).
2. Diagnostic Test:
   • PTP 10-90%: Offer functional testing (CTCA, stress ECG, or imaging).
   PTP >90%: Consider direct referral for ICA.
3. Test Result & Management: Similar to NICE: optimise medical therapy and consider revascularisation for uncontrolled symptoms on OMT.

Frequently Asked Questions (FAQs)

1. Which guideline should I follow in my NHS trust?

This is a common dilemma. Local commissioning and service configuration often dictate the available pathway. Many NHS trusts are working to implement the NICE CCTA-first model, but this requires significant resource and expertise. It is practical to be familiar with both guidelines and adhere to your local protocol, which may be a hybrid of both. The NICE guideline carries more weight in terms of national standards.

2. What if my patient has a high calcium score on CTCA?

Both guidelines acknowledge that a high Agatston calcium score can make CCTA interpretation difficult. In this scenario, if the CCTA is non-diagnostic, the next step would be functional imaging (as per NICE's contingency plan) to assess for haemodynamically significant ischaemia.

3. How do I manage a patient with non-obstructive CAD on CCTA but ongoing symptoms?

This is a key strength of the anatomical approach. Both NICE and RCP highlight that this finding should prompt consideration of microvascular angina. Management includes reassurance that there is no obstructive disease and a trial of anti-anginal medications (e.g., beta-blockers, CCBs, ranolazine).

4. Is stress ECG still relevant?

Yes, but its role is more limited. In the RCP PTP-based pathway, it remains an option for patients with an intermediate PTP, especially if they have a normal ECG and are able to exercise. In the NICE pathway, its role is diminished, primarily for situations where other tests are not feasible.

5. Are there differences in lifestyle advice?

No. Both guidelines provide identical, strong recommendations for lifestyle modification: smoking cessation, healthy diet, weight management, and regular physical activity as a cornerstone of management.

Source Links

• NICE Guideline CG126 (Stable angina): NICE CG126 (Last updated July 2023).
• RCP London Clinical Guideline (Stable chest pain): RCP London stable chest pain guideline (2023) (Published 2023).