Changes

January to March 2026 — reviewed. A literature search was conducted in January 2026 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The recommendations on pre-hospital management of acute heart failure have been updated in line with NICE guidance on the diagnosis and management of acute heart failure [NICE, 2021].

Update

Goals

To support primary healthcare professionals to:

• Decide whether emergency admission is required.
• Diagnose the underlying cause of chest pain.
• Decide if the person needs to be referred for further investigation or treatment.

Outcome measures

Audit criteria

QOF indicators

QIPP - Options for local implementation

NICE quality standards

What is chest pain?

• The term ‘chest pain’ refers to pain or discomfort in the thorax and may be used to describe a variety of uncomfortable or unpleasant sensations in the chest (such as pain, pressure, heaviness, tightness, or burning).
• Chest pain is commonly classified into cardiac or non-cardiac causes.

[McConaghy, 2020; ACC/AHA, 2021; NICE, 2022; ESC, 2024a]

What causes chest pain?

• The likelihood of the cause of chest pain depends on the clinical setting — cardiovascular disorders (such as acute coronary syndrome) are found more commonly in people presenting with chest pain to Accident and Emergency departments.
• Causes of chest pain can be categorized as:
  • Cardiac:
    • Acute coronary syndrome (includes unstable angina, ST-segment elevation myocardial infarction [STEMI] and non-ST-segment-elevation myocardial infarction [NSTEMI]).
    • Angina.
    • Myocarditis/pericarditis.
    • Cardiomyopathy.
    • Acute heart failure.
    • Aortic valve stenosis.
    • Coronary spasm.
  • Pulmonary:
    • Pulmonary embolism.
    • Pneumothorax.
    • Pneumonia.
    • Bronchitis.
    • Pleural irritation.
    • Malignancy.
  • Vascular:
    • Aortic dissection.
    • Symptomatic aortic aneurysm.
  • Gastrointestinal:
    • Oesophagitis, reflux or oesophageal spasm.
    • Peptic ulcer or gastritis.
    • Pancreatitis.
    • Cholecystitis.
    • Oesophageal rupture.
  • Musculoskeletal disorders:
    • Chest trauma.
    • Muscle injury or inflammation.
    • Costochondritis.
    • Cervical spine pathologies.
  • Other causes:
    • Psychological disorders such as anxiety.
    • Herpes zoster.
    • Anaemia.
    • Sickle cell crisis.
    • Sarcoidosis.
• Data is limited, but studies suggest that non-specific chest pain (no cause identified) is found in up to 16% of people presenting to primary care with chest pain.
• For more information, see the sections on cardiac causes, pulmonary causes, and other causes of chest pain.

[Ebell, 2011; Winzenberg, 2015; Barstow, 2017; Hoorweg, 2017; Frieling, 2018; Harskamp et al, 2019; Dwight, 2020; McConaghy, 2020; ACC/AHA, 2021; Martin, 2022; Jordan, 2023; ESC, 2024a; Rahman, 2024]

How common is chest pain?

• Chest pain accounts for about 1–2% of all consultations in primary care in the UK, and around 5% of visits to Accident and Emergency departments [Ruigomez, 2009; Harskamp et al, 2019; Kleton, 2021; Jordan, 2023].
• Studies carried out in Europe of the prevalence of chest pain among people presenting to primary care approximately concur with these rates. 
  • A prospective study investigating around 190,000 German primary care presentations found chest pain to be the primary cause in 0.7%. In people presenting with chest pain, pain was diagnosed as chest wall pain in 46.6%, stable angina in 11.1%, and due to psychogenic disorders in 9.5%; and 3.6% had acute coronary syndrome [Bösner, 2009]. 
  • The rate was 1.2% in a similar study carried out in Belgium and the Netherlands that included 22,294 primary care presentations [Hoorweg, 2017]. In 8.4% of people presenting with chest pain in this study, a life-threatening underlying cause (such as myocardial infarction) was identified.
  • In both studies, chest pain occurred more often in women (55.9% and 56.6%, respectively) than in men. 

How should I assess a person with chest pain?

• The initial aim of assessment is to identify or exclude a serious cause of chest pain which needs immediate hospital admission, such as acute coronary syndrome or pulmonary embolism.
• To determine the cause of chest pain: 
  • Take a detailed medical history.
  • Examine the person.
  • Organize appropriate investigations based on the suspected cause, unless immediate hospital admission is necessary.

What history should I take from a person with chest pain?

• Check whether the person currently has chest pain.
  • If they are pain-free, ask when their last episode of pain was, and in particular, if it was within the last 12 hours. 
• Ask about:
  • The nature, onset, duration, site, and radiation of chest pain. 
    • An acute onset, with central or band-like chest pain which radiates to the person's jaw, arms, or back, is strongly suggestive of cardiac chest pain. 
    • Persistent, localized chest pain is more suggestive of a pulmonary or musculoskeletal cause.
    • A history of preceding trauma can help differentiate between cardiac and non-cardiac causes.
  • Exacerbating and relieving factors of chest pain. 
    • Chest pain provoked by exertion and relieved by rest or GTN is more typical of angina. For more information, see the CKS topic on Angina.
    • Chest pain that is related to inspiration (pleuritic) may suggest a musculoskeletal or pulmonary cause.
  • Associated symptoms such as breathlessness, nausea, sweating, palpitations, dizziness, cough, haemoptysis, fever, rash, dysphagia and reflux. 
    • Breathlessness can be seen with cardiac or pulmonary causes of chest pain.
    • Nausea and sweating are often associated with acute coronary syndrome.
    • Palpitations may be physiological or due to an underlying arrhythmia and associated with dizziness and pre-syncope/ collapse. For more information, see the CKS topic on Palpitations.
• Also ask about a history of:
  • Chest pain and previous investigations (for example, ECG [electrocardiogram], chest X-ray, or coronary angiogram).
    • Do not rule out a cardiac cause for chest pain on the basis of a normal resting 12-lead ECG.
    • An abnormal ECG makes the diagnosis of coronary artery disease more likely, but does not confirm that the chest pain is stable angina.
    • A recent normal coronary angiogram is helpful to exclude coronary artery disease as a cause of chest pain.
  • Angina, myocardial infarction, or other cardiovascular disease, and coronary revascularisation.
    • Assess for cardiovascular risk factors (such as older age, male sex, smoking, hypertension, diabetes mellitus, increased cholesterol and other lipid levels, and a family history of cardiovascular disease) — risk factors increase the likelihood of significant coronary artery disease.
  • Respiratory and gastroenterological disease, musculoskeletal problems, and previous trauma — musculoskeletal and gastrointestinal disorders are common causes of chest pain in primary care and are often overlooked.
  • Anxiety and depression — psychogenic or non-specific chest pain is a common cause of chest pain in primary care and should be considered if there are clinical features suggesting the diagnosis. For more information, see the CKS topics on Depression and Generalized anxiety disorder.
  • Drug history including over the counter and illicit drug use – cocaine and methamphetamine use can lead to myocardial ischemia.

How should I examine a person with chest pain?

• Carry out a physical examination for people with chest pain. This should include:
  • General appearance — check for pallor and sweating (shock).
  • A cardiovascular examination.
    • Heart sounds (for murmurs and pericardial rub).
    • Blood pressure in both arms (possible aortic dissection).
    • Pulse rate and rhythm (shock and arrhythmias).
    • Jugular venous pressure.
    • Carotid pulse.
    • Ankles (for oedema, indicating heart failure).
  • A respiratory examination.
    • Listen to the person's lung fields for signs of infection, pulmonary oedema, and reduced air entry.
    • Measure the respiratory rate and carry out pulse oximetry (low oxygen saturation).
  • Chest wall examination.
    • Palpate for tenderness, and assess whether movement of the chest wall reproduces the pain (suggestive of musculoskeletal chest pain).
  • Abdomen — check for tenderness (gallstones, pancreatitis, or peptic ulceration).
  • Neck — check for localized tenderness and stiffness (cervical spondylosis or osteoarthritis) and lymphadenopathy.
  • Legs — check for swelling or tenderness (deep vein thrombosis).
  • Skin — check for rashes (shingles) and bruising (rib fracture). 
  • Temperature — check for raised temperature, especially over 38.5ºC (infection, pericarditis, or pancreatitis).

What investigations should I consider for a person with chest pain?

• If the person with chest pain requires admission or referral to hospital, do not delay management to arrange investigations in primary care.
• If the person does not require immediate admission or referral, consider the following investigations depending on the suspected cause of chest pain:
  • ECG (electrocardiography) — to look for signs of ventricular hypertrophy, arrhythmia, pulmonary embolism, myocardial ischaemia, and acute coronary syndrome (ACS). 
    • An ECG can provide information on heart rhythm (for example, to check for arrhythmias [such as atrial fibrillation] or conduction defects [such as heart block and bundle-branch block]) and identify signs of myocardial ischaemia, hypertrophy, and previous myocardial infarction.
    • Be aware that a normal resting 12-lead ECG does not exclude an ACS.
    • For more information, see the sections on diagnosing acute coronary syndrome and the CKS topics on Angina, Pulmonary embolism and Palpitations.
  • Blood glucose, lipid profiles, and urea and electrolyte levels — to review the person's cardiovascular risk profile.
    • For more information, see the CKS topic on CVD risk assessment and management.
  • Full blood count — to check for anaemia, which may be exacerbating stable angina or indicate another underlying condition.
  • Thyroid function tests — to check for thyroid disease.
    • For more information, see the CKS topics on Hyperthyroidism and Hypothyroidism.
  • Liver function tests and amylase — to check for cholecystitis and pancreatitis.
    • For more information, see the CKS topics on Pancreatitis - chronic and Cholecystitis - acute.
  • C-reactive protein or erythrocyte sedimentation rate (ESR) — for evidence of infection or inflammation.
    • For more information, see the CKS topics on Chest infections - adult, Polymyalgia rheumatica, and Osteoarthritis.
  • Chest X-ray — to look for signs of heart failure and pulmonary pathology (including pleural effusion, pneumonia, pneumothorax, lobar collapse, and lung cancer).
    • For more information, see the CKS topics on Heart failure - chronic and Lung and pleural cancers - recognition and referral.
    • Do not routinely request a chest X-ray for people with angina.
• Organize further investigations depending on the suspected underlying cause of chest pain.

What are the signs and symptoms of cardiac causes of chest pain?

• Acute coronary syndrome (unstable angina and myocardial infarction).
  • For information on the diagnosis of acute coronary syndrome, see the section on acute coronary syndrome.
• Stable angina
  • For information on the diagnosis of stable angina, see the CKS topic on Angina.
• Dissecting thoracic aneurysm
  • Symptoms — sudden tearing chest pain radiating to the back and inter-scapular region.
  • Signs — high blood pressure, blood pressure differentials (different in both arms), inequality in pulses (carotid, radial, femoral), a new diastolic murmur (aortic valve regurgitation), and occasionally a pericardial friction rub. Neurological deficits may be present (such as hemiplegia).
• Pericarditis/cardiac tamponade
  • Symptoms — sharp, constant sternal pain relieved by sitting forward. Pain may radiate to the left shoulder and/or left arm and/or into the abdomen, and is exacerbated by inspiration, lying down, swallowing, and coughing. Other symptoms may include fever, cough, and arthralgia. Cardiac tamponade may have associated breathlessness, dysphagia, cough, and hoarseness.
  • Signs of pericarditis include pericardial friction rub (high-pitched scratching sound, best heard over the left sternal border during expiration).
  • Signs of cardiac tamponade include pulsus paradoxus (decrease in palpable pulse and arterial systolic blood pressure of 10 mmHg on inspiration), hypotension, muffled heart sounds, and jugular venous distention (Beck's Triad).
• Acute congestive cardiac failure
  • Symptoms — ankle swelling, tiredness, severe breathlessness, orthopnea, and coughing (rarely producing frothy, blood-stained sputum).
  • Signs — elevated jugular venous pressure, gallop rhythm, inspiratory crackles at lung bases, and (often) wheeze. 
  • For more information, see the CKS topic on Heart failure - chronic.
• Arrhythmias
  • Symptoms — chest pain associated with palpitations, breathlessness, and syncope (or near syncope).
  • Signs — bradycardia or tachycardia.
  • For more information on the diagnosis of an arrhythmia, see the CKS topic on Palpitations.
• Cardiomyopathies
  • Symptoms — chest pain, shortness of breath, palpitations, fatigue and syncope. Be aware that cardiomyopathies are often asymptomatic and identified incidentally. 
  • Signs — mitral regurgitation, arrhythmia, and signs of heart failure such as shortness of breath, pulmonary and/or peripheral oedema.
  • Stress cardiomyopathy presents in a similar way to acute coronary syndrome — consider in people presenting with angina-like chest pain and a low likelihood of coronary artery disease.

What are the signs and symptoms of pulmonary causes of chest pain?

• Pulmonary embolism
  • Symptoms — acute-onset breathlessness, pleuritic chest pain (worse on inspiration), cough, haemoptysis and/or syncope. Recurrent acute episodes may lead to chronic breathlessness.
  • Signs — tachypnoea of more than 20 breaths per minute, tachycardia, mild pyrexia, signs of deep vein thrombosis (DVT). 
  • For more information, see the CKS topic on Pulmonary embolism.
• Pneumothorax or tension pneumothorax
  • Symptoms — sudden-onset pleuritic pain and breathlessness in people with or without pallor and tachycardia.
  • Signs — reduced chest wall movements, reduced breath sounds, reduced vocal fremitus, and increased resonance of the percussion note on the affected side. Tension pneumothorax can result in rapid development of severe symptoms associated with tracheal deviation away from the pneumothorax, tachycardia, and hypotension.
• Community-acquired pneumonia
  • Symptoms — cough and at least one other symptom of sputum, wheeze, dyspnoea, or pleuritic chest pain.
  • Signs — any focal chest sign (such as dull percussion note, bronchial breathing, coarse crackles, or increased vocal fremitus or resonance), hypoxia and systemic features (such as fever or sweating, myalgia) may be present. There may be signs of an associated pleural effusion.
  • For more information, see the CKS topic on Chest infections - adult.
• Asthma
  • Symptoms — wheeze, breathlessness, cough. Symptoms are variable (often worse at night, first thing in the morning, and upon exercise or exposure to cold or allergens).
  • Signs — there may be none when the person is feeling well. During an acute episode, the respiratory rate is increased, and wheeze is usually present.
  • For more information, see the CKS topic on Asthma.
• Lung or lobar collapse
  • Symptoms — localized chest pain, breathlessness, cough.
  • Signs — reduced chest wall movement on the affected side, dull percussion note with bronchial breathing, reduced or diminished breath sounds.
• Lung cancer
  • Symptoms — chest or shoulder pain, haemoptysis, dyspnoea, weight loss, appetite loss, hoarseness, and cough.
  • Signs — finger clubbing, cervical or supraclavicular lymphadenopathy, thrombocytosis.
  • For more information, see the CKS topic on Lung and pleural cancers - recognition and referral.
• Pleural effusion
  • Symptoms — breathlessness, chest pain (dull or pleuritic) and cough.
  • Signs — hypoxia, reduced chest wall movements on the affected side, stony dull percussion note, diminished or absent breath sounds, and (in people with heart or renal failure) signs of fluid overload.

What are the signs and symptoms of other causes of chest pain?

• Gastrointestinal causes of chest pain include:
  • Acute pancreatitis
    • History — the person may have a history of gallstones or excessive alcohol consumption.
    • Symptoms — sudden-onset severe pain that is typically epigastric, continuous, boring in nature, radiates to the back and is exacerbated by movement and alleviated by leaning forward. Pain may be generalized and radiate to the right upper quadrant, chest, flanks, and lower abdomen; it is relieved by sitting upright and leaning forward, and is worse in the supine position. There is associated nausea and vomiting.
    • Signs — abdominal tenderness (mild tenderness in the upper abdomen to generalized peritonitis), abdominal distension, Cullen's sign (a bluish discolouration around the umbilicus), or Grey–Turner's sign (bluish discolouration around the flank), tachycardia, tachypnoea, hypotension and sweating. There may be a fever.
    • For more information, see the CKS topic on Pancreatitis - acute.
  • Oesophageal rupture
    • History — a recent history of a medical procedure, foreign body ingestion, severe vomiting/retching or oesophageal cancer.
    • Symptoms — thoracic oesophageal perforation leads to chest pain, dyspnoea, and odynophagia.
    • Signs — classical findings include fever and subcutaneous emphysema (around the neck and upper chest wall).
  • Peptic ulcer disease, gastro-oesophageal reflux, oesophageal spasm, or oesophagitis
    • Symptoms — upper abdominal or sub-sternal pain/discomfort, heartburn, gastric reflux, nausea or vomiting. Symptoms commonly occur at night or after consumption of a large meal. Epigastric pain often radiates to the throat and is worse when bending or lying flat. Regurgitation of acid and food into the mouth can occur.
    • For more information, see the CKS topic on Dyspepsia - unidentified cause.
  • Acute cholecystitis
    • History — the person may have a history of gallstones (cholelithiasis).
    • Symptoms — sudden-onset, constant, severe pain in the upper right quadrant; and possibly anorexia, nausea, vomiting, sweating and fever/chills.
    • Signs — tenderness in the upper right quadrant, with or without Murphy's sign (inspiration is inhibited by pain on palpation) on examination. There may also be fever (evidence of sepsis) and jaundice (stone in the bile duct or external compression of the biliary ducts).
    • For more information, see the CKS topic on Cholecystitis - acute.
• Musculoskeletal causes of chest pain include:
  • Rib fracture
    • History — previous history of trauma or coughing.
    • Symptoms — unilateral, sharp chest pain, worse with inspiration.
    • Signs — bruising and tenderness on palpation over the affected rib.
  • Costochondritis
    • Symptoms — sharp, anterior parasternal chest wall pain, exaggerated by breathing, activity, or a particular posture.
    • Signs — tenderness over the costochondral junction and pain in the affected area when palpating the chest wall. In Tietze's syndrome, there is a tender, fusiform swelling of the costal cartilage at the costochondral junction.
  • Spinal disorders (disc prolapse, cervical spondylosis, facet joint dysfunction)
    • Symptoms — dull and aching chest pain aggravated by particular movements of the neck. Pain radiates in a non-segmental distribution down the arm, up into the head, into the shoulder, or across the scapulae. May be associated with headache or dizziness, or pain in the spine.
    • Signs — may be associated with paraesthesia or hyperaesthesia, but with no objective loss of sensation or muscle strength.
    • For more information, see the CKS topic on Neck pain - non-specific.
  • Rheumatoid arthritis
    
    • Symptoms — typically cause persistent symmetrical synovitis of the small joints of the hands and feet, although any synovial joint may be affected.  Pain, swelling, heat, and stiffness may be reported in affected joints. Morning stiffness (lasting at least an hour) is common. Systemic features (malaise, fatigue, fever, sweats, and weight loss) may also be present.
    • Signs — affected joints may feel 'boggy' on palpation. Hard, firm swellings over extensor surfaces may be present.
    • For more information, see the CKS topic on Rheumatoid arthritis.
  • Psoriatic arthritis
    • Symptoms — synovitis commonly involves small joints of the hands and feet, but can also affect the spine and/or entheses. Is less often symmetrical than rheumatoid arthritis. The distal interphalangeal joints may be involved.
    • Signs — psoriasis is present in over 90% of people with psoriatic arthritis.
  • Fibromyalgia
    • Symptoms — widespread musculoskeletal pain and tenderness, poor quality sleep, fatigue, cognitive disturbances.
    • For more information, see the CKS topics on Chronic pain and Tiredness/fatigue in adults.
  • Osteoporotic fracture
    • Symptoms — acute localized pain for rib fractures.
    • Signs — may be associated with height loss or kyphosis. More common in post-menopausal females and people using corticosteroids.
    • For more information, see the CKS topic on Osteoporosis - prevention of fragility fractures.
• Other causes of chest pain include:
  • Psychogenic or non-specific chest pain
    • History — the person has no identifiable risk factors or evidence of a physical cause of chest pain. Anxiety disorders are common, especially panic disorders. The episode is often preceded by a stressful event.
    • Symptoms — Pain may be associated with symptoms of hyperventilation (including tingling of the extremities) and palpitations.
  • Herpes zoster
    • Symptoms — prodrome (typically lasting 2-3 days [although it can last for 7 or more days] 1–5 days before the development of rash), abnormal sensation (for example, burning, tingling, or itch) in the affected skin, there may also be headache, malaise, and photophobia. 
    • Signs — painful maculopapular rash in a unilateral, dermatomal distribution (most commonly on the thorax) that develops into vesicular lesions, which become cloudy within 3–5 days, then crust over and heal within 2–4 weeks.
    • For more information, see the CKS topic on Shingles.
  • Bornholm disease (Coxsackie B virus infection)
    • Symptoms — unilateral, severe pleuritic chest or upper abdominal pain and fever, following an upper respiratory tract infection.
    • Signs — normal examination.
  • Precordial catch (Texidor twinge)
    • Symptoms — more common in children and adolescents. Brief, episodic left-sided chest pain is commonly associated with bending or posture, relieved by deep inspiration or straight posture. No radiation.
    • Signs — normal examination.

Scenario: Management

From age 18 years onwards.

COVID-19

From age 18 years onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on the primary care management of Chest pain, with additional searches in the following areas:

• Diagnosis and assessment of chest pain
• Management of non-cardiac chest pain
• Management of cardiac chest pain

Search dates

May 2021 - January 2026

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• exp Chest Pain/, chest pain.tw, exp Thorax/, exp Pain/
• exp Acute Coronary Syndrome/
• exp Diagnostic Techniques, Cardiovascular/, exp "Laboratory Techniques and Procedures"/
• exp Panic Disorder/, exp Depression/, exp Anxiety/, exp Gastroesophageal Reflux/
• Non cardiac chest pain (NCCP)*.kw.

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
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• Usability.

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• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
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Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

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• Second draft internal review
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Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.