""" Comprehensive NICE Guidelines and NHS Primary Care Knowledge Base Curated clinical summaries covering major high-frequency UK GP presentations: - Hypertension (NICE NG136) - Type 2 Diabetes in Adults (NICE NG28) - Suspected Cancer: 2-Week Wait (2WW) recognition & referral (NICE NG12) - Asthma Diagnosis, Monitoring & Chronic Management (NICE NG80 / BTS-SIGN) - Chronic Kidney Disease (CKD) Assessment & Management (NICE NG203) - Depression in Adults (NICE NG222) - Lower Urinary Tract Symptoms / UTI in Adults (NICE NG109 / UKHSA) - Atrial Fibrillation Management & Anticoagulation (NICE NG196) - Dyspepsia & Gastro-oesophageal Reflux (NICE CG184) - Chest Pain of Recent Onset (NICE CG95) """ NICE_GUIDELINES_DB = [ { "id": "NICE-NG136", "title": "Hypertension in adults: diagnosis and management", "guideline_code": "NICE NG136", "category": "Cardiovascular", "keywords": ["hypertension", "high blood pressure", "bp", "ramipril", "amlodipine", "losartan", "acei", "arb", "ccb", "thiazide", "indapamide", "abpm", "hbpm", "clinic bp"], "diagnostic_criteria": ( "Diagnosis requires Clinic BP >=140/90 mmHg followed by Ambulatory Blood Pressure Monitoring (ABPM) " "or Home Blood Pressure Monitoring (HBPM) daytime average >=135/85 mmHg.\n" "Stage 1: Clinic 140/90 to 159/99 AND ABPM/HBPM 135/85 to 149/89.\n" "Stage 2: Clinic >=160/100 AND ABPM/HBPM >=150/95.\n" "Severe / Stage 3: Clinic systolic >=180 or diastolic >=120 (check for papilloedema/retinal haemorrhage or red-flag target organ damage; refer same-day if acute chest pain, heart failure, confusion, or visual loss)." ), "management_pathway": ( "Treatment targets (<80 years): Clinic <140/90 mmHg; ABPM/HBPM <135/85 mmHg.\n" "Treatment targets (>=80 years): Clinic <150/90 mmHg; ABPM/HBPM <145/85 mmHg.\n\n" "Step 1 Pharmacotherapy:\n" "• Under 55 years and NOT of black African or African-Caribbean family origin: Offer ACE inhibitor (e.g., Ramipril 2.5-10mg OD) OR Angiotensin Receptor Blocker (ARB, e.g., Losartan 50-100mg OD or Candesartan).\n" "• Aged >=55 years OR of black African or African-Caribbean origin of any age: Offer Calcium Channel Blocker (CCB, e.g., Amlodipine 5-10mg OD).\n" "• If CCB not tolerated or heart failure/high oedema risk: Offer thiazide-like diuretic (Indapamide 1.5mg MR or 2.5mg OD).\n\n" "Step 2:\n" "• Combine ACEi/ARB + CCB (or Indapamide if CCB not tolerated).\n" "• In black African/Caribbean origin: Offer ARB in preference to ACEi.\n\n" "Step 3:\n" "• Triple therapy: ACEi/ARB + CCB + Thiazide-like diuretic (Indapamide).\n\n" "Step 4 (Resistant Hypertension):\n" "• Confirm true resistant hypertension with repeat ABPM/HBPM and adherence check.\n" "• If blood potassium <=4.5 mmol/L: Add low-dose Spironolactone (25mg OD) - monitor U&Es closely.\n" "• If blood potassium >4.5 mmol/L: Add Alpha-blocker (Doxazosin) or Beta-blocker (Bisoprolol).\n" "• If uncontrolled, refer to specialist hypertension clinic." ), "red_flags": [ "Clinic BP >=180/120 mmHg with new confusion, altered mental state, or visual disturbance (hypertensive encephalopathy).", "Severe hypertension with papilloedema or retinal haemorrhages (malignant/accelerated hypertension) - emergency admission.", "Chest pain, acute breathlessness, or signs of acute heart failure/aortic dissection.", "Suspected phaeochromocytoma (labile BP, headache, diaphoresis, tachycardia)." ], "monitoring": "U&Es (eGFR, creatinine, potassium) before starting ACEi/ARB/diuretic and repeat within 2-4 weeks after dose titration. Routine annual review once controlled." }, { "id": "NICE-NG28", "title": "Type 2 diabetes in adults: management", "guideline_code": "NICE NG28", "category": "Endocrine / Metabolic", "keywords": ["diabetes", "t2dm", "type 2 diabetes", "hyperglycaemia", "metformin", "sglt2", "dpp4", "glp1", "hba1c", "dapagliflozin", "empagliflozin", "sitagliptin", "gliclazide", "diabetic kidney disease", "diabetic nephropathy", "ng28", "urine acr", "microalbuminuria", "dka", "euglycaemic dka", "metformin contraindicated"], "diagnostic_criteria": ( "HbA1c >= 48 mmol/mol (6.5%) confirms diagnosis.\n" "If patient is symptomatic (polyuria, polydipsia, weight loss), a single test suffices.\n" "If asymptomatic, repeat HbA1c in 2-4 weeks for confirmation.\n" "Prediabetes / Impaired fasting glucose: HbA1c 42-47 mmol/mol (refer to NHS Diabetes Prevention Programme)." ), "management_pathway": ( "Target HbA1c:\n" "• 48 mmol/mol (6.5%) on lifestyle or monotherapy without hypoglycaemia risk (e.g. Metformin).\n" "• 53 mmol/mol (7.0%) on drug associated with hypoglycaemia (e.g., sulfonylurea, insulin).\n\n" "First-line Pharmacotherapy:\n" "• Standard-release Metformin (titrate from 500mg OD up to 1g BD with meals to minimize GI side-effects). If GI intolerant, switch to Metformin MR.\n" "• If established Atherosclerotic Cardiovascular Disease (ASCVD) or high risk (QRISK3 >10%) OR Heart Failure (HF) OR Chronic Kidney Disease (CKD with eGFR 20-60 or uACR >3mg/mmol): Add SGLT2 inhibitor (e.g. Dapagliflozin 10mg OD or Empagliflozin 10mg OD) concurrently or as dual first-line.\n\n" "Metformin Renal Dosing Adjustments:\n" "• Review dose if eGFR <45 mL/min/1.73m2 (max 1000mg/day); stop / discontinue metformin if eGFR <30 mL/min/1.73m2 (contraindicated <30 due to risk of lactic acidosis).\n\n" "SGLT2 Inhibitor Safety (Euglycaemic DKA Alert):\n" "• Warn patients of risk of euglycaemic DKA (diabetic ketoacidosis with normal/near-normal glucose). If patient presents with nausea, abdominal pain, deep rapid breathing: urgently test blood ketones, stop SGLT2i immediately, and arrange emergency hospital admission.\n\n" "Diabetic Kidney Disease Monitoring (NICE NG28):\n" "• Routine baseline blood and urine monitoring: measure annual urine albumin to creatinine ratio (uACR / ACR) and serum creatinine / eGFR.\n\n" "Second-line / Dual Therapy (if HbA1c rises to >=58 mmol/mol):\n" "• If Metformin + SGLT2i already used: Consider DPP-4 inhibitor (e.g. Sitagliptin 100mg OD, linagliptin), Pioglitazone, or Sulfonylurea (Gliclazide 40-160mg daily).\n" "• GLP-1 receptor agonists (e.g. Semaglutide/Dulaglutide): Recommended if BMI >=35 kg/m2 (or <35 if insulin would have significant occupational/psychological consequences, or weight loss would benefit comorbidities)." ), "red_flags": [ "Diabetic Ketoacidosis (DKA) or Hyperosmolar Hyperglycaemic State (HHS): marked dehydration, drowsiness, Kussmaul breathing, blood ketones >3.0 mmol/L, or glucose >30 mmol/L.", "Diabetic foot ulceration with systemic sepsis, ascending cellulitis, or limb ischaemia (refer to multidisciplinary foot service within 24h or same-day admission).", "Suspected new Type 1 Diabetes (rapid weight loss, young age, ketosis)." ], "monitoring": "Review HbA1c every 3-6 months until stable, then every 6 months. Annual diabetic review: fundus photography, foot risk stratification, urine ACR (microalbuminuria), lipid profile, eGFR." }, { "id": "NICE-NG12", "title": "Suspected cancer: recognition and referral (2-Week Wait / Urgent Cancer Pathway)", "guideline_code": "NICE NG12", "category": "Oncology / Urgent Referral", "keywords": ["2ww", "2-week wait", "cancer", "referral", "haematuria", "haemoptysis", "dysphagia", "weight loss", "breast lump", "postmenopausal bleeding", "post-menopausal bleeding", "vaginal bleeding", "bleeding", "menopause", "pmb", "rectal bleeding", "iron deficiency anaemia", "ida", "hoarseness", "fit test", "mole", "melanoma", "skin lesion", "abcde", "dermatology", "excision", "ng12", "2ww dermatology", "asymmetric borders"], "diagnostic_criteria": ( "Clinical threshold: Symptoms or signs with a positive predictive value (PPV) >= 3% for underlying malignancy require an urgent suspected cancer referral for appointment within 2 weeks." ), "management_pathway": ( "Key 2-Week Wait Referral Criteria by Site:\n" "1. Colorectal / Lower GI:\n" " • Faecal Immunochemical Test (FIT): Offer FIT testing in primary care for unexplained bowel habit change, abdominal pain, or weight loss without rectal bleeding.\n" " • Urgent 2WW Colonoscopy/Referral if: FIT >= 10 ug Hb/g faeces, OR age >=40 with unexplained weight loss and abdominal pain, OR age >=50 with unexplained rectal bleeding, OR age >=60 with iron deficiency anaemia (IDA).\n" "2. Upper GI (Oesophageal / Gastric):\n" " • Urgent 2WW direct access endoscopy if: Dysphagia (difficulty swallowing at any age), OR age >=55 with weight loss AND upper abdominal pain/reflux/dyspepsia.\n" "3. Gynaecological (Endometrial / Cervical / Ovarian):\n" " • Post-Menopausal Bleeding (PMB, unexplained bleeding >12 months after menopause): Urgent 2WW ultrasound/hysteroscopy.\n" " • Suspicious cervical mass or ulcer: Urgent 2WW.\n" " • Ovarian cancer: Measure serum CA125 in women age >=50 with persistent bloating, early satiety, pelvic pain, or increased urinary urgency; if CA125 >=35 IU/mL, arrange urgent ultrasound.\n" "4. Breast:\n" " • Age >=30 with unexplained breast lump.\n" " • Age >=50 with discharge or skin changes / retraction.\n" "5. Urological (Bladder / Renal / Prostate):\n" " • Age >=45 with unexplained visible haematuria without UTI, or persisting after successful treatment of UTI.\n" " • Age >=60 with unexplained non-visible haematuria AND dysuria or raised WCC.\n" " • Prostate: Hard, irregular prostate on DRE or age-specific elevated PSA.\n" "6. Respiratory (Lung):\n" " • Urgent CXR within 2 weeks if age >=40 with unexplained haemoptysis, or 2+ of: cough, fatigue, shortness of breath, chest pain, weight loss, appetite loss (especially smokers/asbestos exposure).\n" "7. Skin / Melanoma:\n" " • Suspicious pigmented skin lesion or mole with ABCDE features (Asymmetry, Border irregularity, Colour variation, Diameter >6mm, Evolution) -> Urgent 2WW dermatology referral for specialist excision / biopsy." ), "red_flags": [ "Stridor, superior vena cava obstruction (SVCO), spinal cord compression: require SAME-DAY emergency hospital admission, not routine 2WW." ], "monitoring": "Ensure safety-netting: inform patient about 2WW purpose, confirm patient is available within next 14 days, track referral in GP clinical system (EMIS/SystmOne)." }, { "id": "NICE-NG80", "title": "Asthma: diagnosis, monitoring and chronic asthma management", "guideline_code": "NICE NG80 / BTS-SIGN", "category": "Respiratory", "keywords": ["asthma", "wheeze", "salbutamol", "inhaler", "fev1", "feno", "peak flow", "ics", "laba", "beclometasone", "budesonide", "fluticasone", "mart", "ng80", "acute severe asthma", "severe asthma", "life-threatening", "life-threatening asthma", "feno 40", "prednisolone", "nebulised salbutamol", "short phrases", "silent chest", "asthmatic", "asthma maintenance", "dry cough", "cough", "worse at night", "nocturnal"], "diagnostic_criteria": ( "Objective testing required for diagnosis in age >=5:\n" "• Fractional exhaled nitric oxide (FeNO) test: FeNO >=40 ppb in adults (>=35 ppb in children) confirms eosinophilic airway inflammation and supports asthma diagnosis.\n" "• Spirometry with bronchodilator reversibility (BDR): FEV1/FVC < 0.70 with improvement >=12% and >=200 ml post-salbutamol.\n" "• Peak Expiratory Flow (PEF) variability: >=20% diurnal variability over 2-4 weeks diary." ), "management_pathway": ( "Stepwise Pharmacotherapy (BTS/NICE/GINA):\n" "• Step 1: Low-dose inhaled corticosteroid (ICS, e.g. Beclometasone 100-200mcg/day or Budesonide) PLUS short-acting beta2 agonist (SABA, Salbutamol 100mcg prn).\n" " * Note: Modern guidelines discourage SABA-only monotherapy due to risk of severe exacerbations.\n" "• Step 2: Add Long-Acting Beta2 Agonist (LABA) in fixed combination with ICS (e.g. Formoterol/Budesonide or Fostair). MART (Maintenance and Reliever Therapy) regimen preferred.\n" "• Step 3: Increase ICS to moderate dose, OR add Leukotriene Receptor Antagonist (LTRA, Montelukast 10mg OD nocte).\n" "• Step 4: High-dose ICS/LABA, add Long-Acting Muscarinic Antagonist (LAMA, Tiotropium), or refer to difficult asthma / biologics clinic.\n\n" "Always check inhaler technique and adherence before escalating any step.\n\n" "Acute Adult Asthma Exacerbation Protocol:\n" "• Moderate exacerbation: PEFR 50-75% best/predicted -> Inhaled SABA (Salbutamol) via spacer + Oral Prednisolone 40-50mg daily for 5 days.\n" "• Acute severe asthma (RR >=25, HR >=110, speaking in short phrases, PEFR 33-50%): High-dose nebulised salbutamol 5mg with oxygen, oral prednisolone 40-50mg, and urgent hospital admission.\n" "• Life-threatening asthma exacerbation (PEFR <33%, SpO2 <92%, silent chest, cyanosis, exhaustion): Immediate 999 ambulance blue-light emergency transfer, high-flow oxygen, nebulised salbutamol + ipratropium, and IV hydrocortisone or oral prednisolone." ), "red_flags": [ "Acute Severe Asthma: PEF 33-50% predicted, inability to complete sentences in one breath, RR >=25/min, HR >=110 bpm -> High-dose SABA via spacer or nebuliser + oral prednisolone 40-50mg + arrange emergency transfer if not rapidly resolving.", "Life-Threatening Asthma: PEF <33% predicted, SpO2 <92%, silent chest, cyanosis, bradycardia, confusion/exhaustion -> 999 Immediate blue-light transfer, high-flow O2, nebulised Salbutamol + Ipratropium, IV access." ], "monitoring": "Annual asthma review using Asthma Control Test (ACT) score, check inhaler technique, issue Personalised Asthma Action Plan (PAAP)." }, { "id": "NICE-NG203", "title": "Chronic kidney disease: assessment and management", "guideline_code": "NICE NG203", "category": "Renal", "keywords": ["ckd", "kidney", "egfr", "creatinine", "proteinuria", "uacr", "urine acr", "dapagliflozin", "ramipril", "losartan", "potassium"], "diagnostic_criteria": ( "CKD diagnosed if eGFR <60 ml/min/1.73m2 OR urine albumin-to-creatinine ratio (uACR) >= 3 mg/mmol sustained on repeat test for >=3 months.\n" "Staging: G1 (>=90), G2 (60-89), G3a (45-59), G3b (30-44), G4 (15-29), G5 (<15 / kidney failure).\n" "Albuminuria: A1 (<3 mg/mmol, normal), A2 (3-30 mg/mmol, microalbuminuria), A3 (>30 mg/mmol, severe)." ), "management_pathway": ( "Blood pressure target: Clinic <140/90 mmHg (or <130/80 mmHg if uACR >=70 mg/mmol or in diabetes with uACR >=3 mg/mmol).\n\n" "Renoprotection:\n" "• ACE inhibitor or ARB: Offer if uACR >=30 mg/mmol (or >=3 mg/mmol in patients with diabetes and hypertension). Titrate to maximum tolerated dose.\n" "• SGLT2 Inhibitor (Dapagliflozin 10mg OD or Empagliflozin 10mg OD): Recommended by NICE for adults with CKD (eGFR 20-45 ml/min/1.73m2, or eGFR 45-60 with uACR >=22.6 mg/mmol, or with T2DM) to slow progression and reduce cardiovascular death.\n" "• Statin: Offer Atorvastatin 20mg OD for primary/secondary prevention of CVD in all CKD patients." ), "red_flags": [ "Acute Kidney Injury (AKI): rapid rise in serum creatinine by >=50% in 7 days or >=26 umol/L in 48h.", "eGFR <15 ml/min/1.73m2 (G5) or sustained drop in eGFR >=25% within 12 months.", "uACR >=70 mg/mmol without diabetes (unless known to be caused by diabetic nephropathy and previously investigated).", "CKD with severe hyperkalaemia (K+ >=6.5 mmol/L or >=6.0 with ECG changes): emergency admission." ], "monitoring": "Monitor eGFR and uACR at least annually (G3a A1) up to 4 times a year for high risk (G4/G5 or A3). Check U&Es 1-2 weeks after starting or titrating ACEi/ARB." }, { "id": "NICE-NG222", "title": "Depression in adults: treatment and management", "guideline_code": "NICE NG222", "category": "Mental Health", "keywords": ["depression", "low mood", "anxiety", "phq9", "ssri", "sertraline", "citalopram", "fluoxetine", "cbt", "talking therapy", "suicide"], "diagnostic_criteria": ( "DSM-5 / ICD-11 core symptoms: persistent sadness or low mood, and/or loss of interest or pleasure (anhedonia) for >=2 weeks.\n" "Assess severity using validated tool (e.g. PHQ-9: 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe)." ), "management_pathway": ( "Less severe / Mild depression:\n" "• Do NOT routinely offer antidepressant medication as first-line unless patient explicitly prefers it, has past history of moderate/severe depression, or symptoms persist >=3 months.\n" "• First-line: High-intensity/low-intensity psychological interventions (NHS Talking Therapies / self-help CBT, behavioural activation, group exercise).\n\n" "Moderate to Severe depression:\n" "• Offer a choice of evidence-based psychological therapy (individual CBT) OR an antidepressant (SSRI), or combination.\n" "• First-line SSRI: Sertraline (50mg OD, titrate to max 200mg) or Citalopram (20mg OD, max 40mg, max 20mg in elderly/cardiac risk).\n" "• Sertraline is preferred first-line in patients with concurrent physical illness (e.g. post-MI / cardiovascular disease).\n" "• Advise that onset of therapeutic benefit takes 2-4 weeks; continue treatment for at least 6 months after full remission to prevent relapse." ), "red_flags": [ "Active suicidal ideation with intent, plan, or recent self-harm: urgent mental health crisis team assessment (NHS Crisis Resolution Team / A&E psychiatric liaison).", "Psychotic depression (delusions, auditory hallucinations) or severe self-neglect / refusal of food/fluids: emergency psychiatric admission.", "Suspected bipolar depression (history of hypomania/mania): avoid antidepressant monotherapy without mood stabilizer due to risk of manic switch." ], "monitoring": "Review patient within 1-2 weeks of starting antidepressant (or 1 week if aged <25 years or increased suicide risk). Assess side effects, suicidal ideation, and early response." }, { "id": "NICE-NG109", "title": "Urinary tract infection (lower): antimicrobial prescribing", "guideline_code": "NICE NG109 / UKHSA", "category": "Infectious Disease / Primary Care", "keywords": ["uti", "cystitis", "dysuria", "nitrofurantoin", "trimethoprim", "dipstick", "urine culture", "pyelonephritis"], "diagnostic_criteria": ( "Non-pregnant women <65 with >=2 key symptoms (dysuria, new nocturia, cloudy urine) and no vaginal discharge: diagnosis can be made without urine dipstick.\n" "Urine culture indicated in: pregnancy, men, children, recurrent UTI (>=2 in 6 months or >=3 in 12 months), treatment failure, or suspected pyelonephritis." ), "management_pathway": ( "First-line empirical antimicrobial (adult non-pregnant women):\n" "• Nitrofurantoin: 100mg modified-release BD for 3 days (caution if eGFR <45 ml/min).\n" "• Alternative first-line: Trimethoprim 200mg BD for 3 days (only if low risk of resistance or known sensitive).\n\n" "Men with uncomplicated lower UTI:\n" "• Nitrofurantoin 100mg MR BD for 7 days (or Trimethoprim 200mg BD for 7 days). Always send midstream urine (MSU) culture.\n\n" "Pregnant women:\n" "• Nitrofurantoin 100mg MR BD for 7 days (avoid at term / 36+ weeks due to risk of neonatal haemolysis), or Amoxicillin/Cefalexin based on sensitivities. Always send MSU." ), "red_flags": [ "Upper UTI / Acute Pyelonephritis: flank/loin pain, fever, rigors, nausea/vomiting -> require oral Ciprofloxacin or Co-amoxiclav for 7-14 days; hospital admission if sepsis, vomiting, or pregnant.", "Urosepsis: NEWS2 score >=5, confusion, tachypnoea, tachycardia, hypotensive -> immediate emergency transfer." ], "monitoring": "Advise safety netting: seek medical attention if symptoms worsen, do not improve within 48 hours, or systemic features develop." }, { "id": "NICE-NG196", "title": "Atrial fibrillation: diagnosis and management", "guideline_code": "NICE NG196", "category": "Cardiovascular", "keywords": ["af", "atrial fibrillation", "irregular pulse", "chadsvasc", "hasbled", "orbit", "doac", "apixaban", "edoxaban", "rivaroxaban", "bisoprolol"], "diagnostic_criteria": ( "Suspected in irregular pulse; confirm diagnosis with 12-lead ECG (absence of P waves, irregular RR intervals)." ), "management_pathway": ( "Stroke Risk Stratification:\n" "• Calculate CHA2DS2-VASc score (Congestive heart failure, Hypertension, Age >=75 [2 pts], Diabetes, Stroke/TIA [2 pts], Vascular disease, Age 65-74, Sex category female [1 pt]).\n" "• Offer anticoagulation if score >=2 (men or women), or consider if score 1 in men.\n\n" "Anticoagulation Choice:\n" "• First-line: Direct-acting oral anticoagulant (DOAC, e.g. Apixaban 5mg BD, Edoxaban 60mg OD, or Rivaroxaban 20mg OD) in preference to Warfarin.\n" "• Assess bleeding risk using ORBIT (or HAS-BLED) score to address modifiable bleeding risks (uncontrolled BP, alcohol, concurrent NSAIDs/antiplatelets).\n\n" "Rate Control (First-line in non-acute setting):\n" "• Standard monotherapy: Beta-blocker (Bisoprolol 2.5-10mg OD) OR rate-limiting CCB (Diltiazem or Verapamil - avoid in heart failure).\n" "• Target resting heart rate: <90 bpm (or <110 bpm if asymptomatic and preserved LV function)." ), "red_flags": [ "Haemodynamically unstable AF (SBP <90 mmHg, acute pulmonary oedema, ongoing ischaemia, altered consciousness): emergency 999 hospital admission for urgent DC cardioversion.", "Suspected new stroke or TIA: emergency stroke assessment / same-day TIA clinic referral." ], "monitoring": "Review anticoagulation adherence, bleeding events, renal function (eGFR to adjust DOAC dose), and liver function annually (or every 3-6 months if frail/elderly)." }, { "id": "NICE-CG95", "title": "Recent-onset chest pain of suspected cardiac origin: assessment and diagnosis", "guideline_code": "NICE CG95", "category": "Cardiovascular / Emergency Assessment", "keywords": ["chest pain", "angina", "mi", "myocardial infarction", "acs", "acute coronary syndrome", "ecg", "troponin", "gtn", "aspirin", "retrosternal", "chest tightness", "walking uphill", "exertion", "exertional", "racpc", "ctca", "cg95"], "diagnostic_criteria": ( "Assessment for Acute Coronary Syndrome (ACS) vs. Stable Angina:\n" "• Acute chest pain: Central constricting/heavy chest pain radiating to neck/jaw/left arm, associated with diaphoresis, nausea, or shortness of breath." ), "management_pathway": ( "Acute Suspected ACS Pathway:\n" "• Immediately call 999 for emergency blue-light ambulance transfer to nearest Cardiac Catheterisation Centre / ED.\n" "• Immediate primary care management while awaiting ambulance:\n" " - Soluble Aspirin 300mg chewed (unless known true anaphylaxis).\n" " - Sublingual GTN spray 1-2 puffs (unless SBP <90 mmHg or phosphodiesterase-5 inhibitor used within 24h).\n" " - Perform 12-lead ECG immediately if equipment available (do NOT delay transfer).\n" " - Supplemental O2 only if SpO2 <94% (or <88% in hypercapnic COPD).\n\n" "Stable Chest Pain (Suspected Angina):\n" "• Characterise pain: (1) Constricting discomfort in front of chest/neck/shoulders/jaw/arms; (2) Precipitated by physical exertion; (3) Relieved by rest or GTN within 5 minutes.\n" " - 3 features: Typical angina.\n" " - 2 features: Atypical angina.\n" " - 0-1 feature: Non-anginal chest pain.\n" "• Urgent Rapid Access Chest Pain Clinic (RACPC) referral for CT coronary angiography (CTCA) within 2 weeks if typical or atypical angina." ), "red_flags": [ "Pain persisting >15 minutes at rest or newly accelerating in frequency/severity (Unstable Angina / STEMI / NSTEMI) -> 999 Emergency.", "Tearing chest pain radiating through to back (Suspected Aortic Dissection) -> 999 Emergency (avoid Aspirin).", "Pleuritic chest pain with acute breathlessness and tachycardia (Suspected Pulmonary Embolism - Wells score)." ], "monitoring": "For confirmed stable angina: start secondary prevention (Aspirin 75mg OD, Atorvastatin 80mg OD) + anti-anginal (Bisoprolol or Amlodipine) + PRN sublingual GTN." }, { "id": "NICE-CG184", "title": "Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management", "guideline_code": "NICE CG184", "category": "Gastroenterology", "keywords": ["dyspepsia", "indigestion", "heartburn", "gerd", "gord", "reflux", "ppi", "omeprazole", "lansoprazole", "h pylori", "helicobacter", "cg184", "haematemesis", "melaena", "vomiting blood", "tarry stools", "upper gi bleed", "burning retrosternal", "burning retrosternal pain", "acid taste", "antacids", "peptic ulcer", "nsaid", "naproxen", "endoscopy"], "diagnostic_criteria": ( "First step: Check for RED FLAG cancer alarm features (age >=55 with unexplained weight loss AND upper abdominal pain/reflux; or dysphagia at any age -> 2WW urgent endoscopy).\n" "In uninvestigated dyspepsia without red flags: offer lifestyle advice + test-and-treat for Helicobacter pylori (urea breath test or stool antigen test)." ), "management_pathway": ( "Management of H. pylori negative or uncomplicated GORD:\n" "• Full-dose Proton Pump Inhibitor (PPI, e.g. Omeprazole 20mg OD or Lansoprazole 30mg OD) for 4 weeks (GORD requires 4-8 weeks).\n" "• If symptoms recur after stopping, step down to lowest effective maintenance dose PRN.\n\n" "If H. pylori positive:\n" "• First-line 7-day eradication triple therapy: PPI (e.g. Omeprazole 20mg BD) + Amoxicillin 1g BD + Clarithromycin 500mg BD (or Metronidazole 400mg BD if penicillin allergic).\n" "• Re-test for eradication only if symptoms persist or patient has high ulcer recurrence risk (at least 2 weeks after stopping PPI and 4 weeks after stopping antibiotics).\n\n" "Upper GI Bleeding & Acute Peptic Ulcer Emergencies:\n" "• Sudden haematemesis (vomiting blood), melaena (black tarry stools), or collapse (e.g. from high-dose NSAID/Naproxen-induced ulcer): Call 999 for immediate emergency hospital admission, urgent IV fluid resuscitation, and inpatient endoscopy.\n\n" "Endoscopy Referral Criteria:\n" "• Urgent 2WW endoscopy: if alarm features (dysphagia at any age, or age >=55 with weight loss + dyspepsia/reflux, or upper GI bleed/mass).\n" "• Non-urgent endoscopy: consider for patients with refractory symptoms unresponsive to full-dose PPI trials or recurrent vomiting." ), "red_flags": [ "Dysphagia (difficulty swallowing) at any age -> immediate 2-week wait referral.", "Unexplained upper abdominal mass or persistent vomiting -> urgent 2WW.", "Haematemesis or melaena (acute upper GI bleed) -> same-day emergency hospital admission." ], "monitoring": "Review long-term PPI indications annually to reduce risks of hypomagnesaemia, Clostridioides difficile, and bone fractures." } ]