Rapid Access Cardiology Research Articles

Safety outcomes of suspected cardiac pathology assessed in an ambulatory rapid-access cardiology clinic

Safety outcomes of suspected cardiac pathology assessed in an ambulatory rapid-access cardiology clinic

Can existing electronic medical records be used to quantify cardiovascular risk at point of care?

Using electronic data for cardiovascular risk stratification could help in prioritising healthcare access and optimise cardiovascular prevention. To determine whether assessment of absolute cardiovascular risk (Australian absolute cardiovascular disease risk (ACVDR)) and short-term ischaemic risk (History, ECG, Age, Risk factors, and Troponin (HEART) score) is possible from available data in Electronic Medical Record (EMR) and My Health Record (MHR) of patients presenting with acute cardiac symptoms to a Rapid Access Cardiology Clinic (RACC). Audit of EMR and MHR on 200 randomly selected adults who presented to RACC between 1 March 2017 and 4 February 2020. The main outcomes were the proportion of patients for which ACVDR score and HEART score could be calculated. Mean age was 55.2 ± 17.8 years and 43% were female. Most (85%) were referred from emergency for chest pain (52%). Forty-six percent had hypertension, 35% obesity, 20% diabetes mellitus, 17% ischaemic heart disease and 18% were current smokers. There was no significant difference in MHR accessibility with age, gender and number of comorbidities. An ACVDR score could be estimated for 17.5% (EMR) and 0% (MHR) of patients. None had complete data to estimate HEART score in either EMR or MHR. Most commonly missing variables for ACVDR score were blood pressure (MHR) and high-density lipoprotein cholesterol (EMR), and for HEART score the missing variables were body mass index and comorbidities (MHR and EMR). Significant gaps are apparent in electronic medical data capture of key variables to perform cardiovascular risk assessment. Medical data capture should prioritise the collection of clinically important data to help address gaps in cardiovascular management.

Feasibility of m-Health Smoking Cessation Initiative in a Metropolitan Rapid Access Cardiology Clinic (RACC)

Feasibility of m-Health Smoking Cessation Initiative in a Metropolitan Rapid Access Cardiology Clinic (RACC)

Rapid Access Arrhythmia Clinics (RAACs) Versus Usual Care: Improving Efficiency and Safety of Arrhythmia Management

Rapid access cardiology services have been proposed for assessment of acute cardiac conditions via an outpatient model-of-care that potentially could reduce hospitalisations. We describe a new Rapid Access Arrhythmia Clinic (RAAC) and compare major safety endpoints to usual care. We matched 312 adult patients with suspected arrhythmia in RAAC to historical age and sex-matched controls discharged from hospital within Western Sydney Local Health District with suspected arrhythmia. The primary endpoint was a composite of time to first unplanned cardiovascular hospitalisation or cardiac death over 12 months. The average age of RAAC patients was 52.2±18.8 years and 51.6±18.8 years for controls, and 48.4% were female in both groups. Mean time from referral to first attended RAAC appointment was 10.5 days. Most were referred from emergency (177, 56.7%) and cardiologists at time of discharge (65, 20.8%). The most common reason for referral was palpitations (180, 57.7%). In total, 155 (49.7%) had a documented arrhythmia, with the most common being atrial fibrillation/flutter (88, 28.2%). The primary endpoint occurred in 35 (11.2%) patients in the RAAC pathway (97.1[95% CI 70-131.3] per 1,000 person-years), compared to 72 (23.1%) patients for usual care controls (229.5[95% CI 180.2-288.1] per 1,000 person-years). Using a propensity score analysis, RAAC pathway significantly reduced the primary endpoint by 59% compared to usual care (HR 0.41, 95% CI 0.27-0.62; p<0.001). RAACs for the early investigation and management of suspected arrhythmia is superior to usual care in terms of reduction in unplanned cardiovascular hospitalisation and death.

Text messages for primary prevention of cardiovascular disease: the TextMe2 randomised controlled trial protocol

IntroductionMobile health may be an effective means of delivering customised individually directed health promotion interventions for cardiovascular disease (CVD) primary prevention. The aim of this study is to evaluate the...

538 Real World Review of an Australian Outer-Metropolitan Rapid Access Cardiology Clinic (RACC)

Rapid access cardiology clinics (RACC) have increased in Australia following success internationally. However, there remains scant data about RACC’s in Australian outer-metropolitan centers. We established a publicly-funded, multi-centered, outer-metropolitan RACC focused on timely access to cardiology review and investigations. Our aim was to describe our 6-month data. Referrals were accepted from emergency departments (ED) of two outer-metropolitan hospitals. A nurse organised appointments before a cardiologist reviewed all patients. If necessary, further investigations were arranged and a single follow-up organised. 209 consecutive patients were analysed with a mean age of 62.3 years, including 105 (50%) females. The ED length-of-stay (including patients admitted to short-stay) mean improved by 98 minutes and median by 30 minutes between the first and final 50 patients. The mean time from referral to RACC appointment was 7.6 days (SD; 5.8). Stress testing was conducted in 53 patients (25%) and computed tomography coronary angiograms (CTCA) in 139 (67%) of which 86 (62%) were found to have coronary artery disease. The mean time from the first appointment to a publicly-funded CTCA was 3.4 days (SD; 3.05). 13 patients (6%) were referred for invasive angiograms. Primary and secondary-prevention measures included commencement of aspirin in 42 patients (20%) and statin commencement in 44 (21%) or up-titration in 23 (11%). 45 patients (22%) were referred to cardiac rehabilitation and smoking-cessation discussed with 19 (9%). RACC is an efficient and effective resource in the follow-up and risk-stratification of patients with low-intermediate risk chest pain and can be successfully implemented in an outer-metropolitan setting.

426 Use of Coronary Computed Tomographic Angiography (CCTA) for Absolute Risk Reduction in a Rapid Access Cardiology Clinic (RACC)

The RACC service within the Central Coast Local Health District utilises CCTA for quick and accurate investigation of patients discharged from the Emergency Department with low- intermediate risk chest pain. As demonstrated in the SCOT-HEART trial, CCTA identifies Coronary Artery Disease (CAD) in patients with chest pain, and facilitates appropriate and timely use of medical therapy, and supports more judicious use of invasive angiography1. A cross sectional analysis of all patients referred to the RACC was performed. We identified those who proceeded to CCTA, and compared changes to medical management, including addition or titration of statin as well as proceeding to angiography. Over the 6 month period 202 patients were seen in the RACC, of these 137 (68%) underwent CCTA, with 83 (61%) having newly diagnosed non obstructive CAD and 51 (37%) resulted in no CAD. Obstructive CAD was found in 1 of these patients, resulting in angiography and revascularisation. With a new diagnosis of non obstructive CAD and LDL-C >1.8, statin therapy was commenced in 45 (54%) of patients, where there was evidence of suboptimal lipid control, statin therapy was increased in 24 (29%)3.Aspirin was commenced for 42 (51%) of these patients. For support with lifestyle modifications such as smoking cessation, diet and exercise, 45 (54%) patients were referred to Cardiac Rehabilitation. Utilising CCTA to diagnose CAD within our RACC model facilitates timely implementation of primary and secondary preventative therapies supporting a reduced absolute risk for CVD events in 5 years2.

Early Results of the Prince of Wales Hospital Rapid Access Cardiology Clinic (RACC)

Background: Due to low bed availability at the Prince of Wales Hospital, a safe and timely pathway for low-risk cardiology outpatient evaluation was established. Similar clinics have limited their focus to chest pain presentations, whereas the scope of this clinic encompassed all general cardiology presentations. Our objective was to evaluate the implementation and benefit of the first six months of the Rapid Access Cardiology Clinic (RACC). Methods: Patient, presentation, and clinical outcome data was retrospectively audited between August 2018 and February 2019. Results: 63 patients were reviewed in the RACC (63% male, mean age 52.7 years). 79% of patients were reviewed within 3 days of referral. 59% of referrals were for assessment of chest pain, with the remainder including AF/flutter, SVT, palpitations, and syncope. Polypharmacy was present in 8% of patients. The predominant investigations performed were rest and stress echocardiography (43% and 49% respectively). 24 patients had subsequent outpatient investigations arranged, with 11 patients having a new medication prescribed. Only 1 patient required direct admission following review, with 33 (52%) being referred for ongoing cardiology follow up, and 25 (40%) being discharged from cardiology services. An estimated 31 inpatient bed days were saved as a result of this clinic Conclusion: A Rapid Access Cardiology Clinic provides an alternative pathway to inpatient investigation for a subset of low-risk general cardiology presentations, not only chest pain. Results indicate a safe and efficient means of accessing outpatient cardiology investigation.

Rapid Access Cardiology (RAC) Services Within a Large Tertiary Referral Centre—First Year in Review

Rapid Access Cardiology (RAC) services are hospital co-located cardiologist-led outpatient clinics providing prompt assessment and management of chest pain. This service model is part of chest pain management in the United Kingdom. However, little data exists on RAC services in Australia. Our aim was to describe the introduction of RAC services to an Australian tertiary centre (utility, safety, and acceptability). Referrals were accepted for low-intermediate risk chest pain. Referrer and patient clinical data was collected prospectively in the first year of RAC - 4 February 2015 to 4 February 2016. Data was linked to hospital presentations/admissions to identify readmissions/mortality data. Among 520 patients (55.0% male, mean age 55.2 years), 87.6% were referred from emergency and 68.4% assessed within 5 days. The final diagnosis was new coronary artery disease (CAD) in 7.9%, and 81.3% had ≥2 cardiovascular risk factors (diabetes, hyperlipidaemia, hypertension, overweight/obesity, smoker, pre-existing CAD, and chronic renal failure). On average, 0.8 cardiac tests were ordered per person. In total, 35 (6.7%) had invasive coronary angiograms, with 51.4% having obstructive CAD. Patients reported in surveys (82.8% response rate) that 93.0% "strongly agreed" RAC services were useful to the community. Referrers were also "very satisfied" with RAC (7/17) or "satisfied" (9/17). Furthermore, of 336 referrals, referrers reported without RAC they would admit the patient in 11.3% of cases. There were 4.8% (25/520) unplanned cardiovascular readmissions and 0.6% (3/520) of these were for acute coronary syndromes and no deaths. Outpatient RAC services are an accepted, effective and safe pathway for management of low-intermediate risk chest pain.

Rapid‐access cardiology services: can these reduce the burden of acute chest pain on Australian and New Zealand health services?

Chest pain is common and places a significant burden on hospital resources. Many patients with undifferentiated low- to intermediate-risk chest pain are admitted to hospital. Rapid-access cardiology (RAC) services are hospital co-located, cardiologist-led outpatient clinics that provide rapid assessment and immediate management but not long-term management. This service model is described as part of chest pain management and the National Service Framework for coronary heart disease in the United Kingdom (UK). We review the evidence on the effectiveness, safety and acceptability of RAC services. Our review finds that early assessment in RAC outpatient services of patients with suspected angina, without high-risk features suspicious of an acute coronary syndrome, is safe, can reduce hospitalisations, is cost effective and has good medical practitioner and patient acceptability. However, the literature is limited in that the evaluation of this model of care has been only in the UK. It is potentially suited to other settings and needs further evaluation in other settings to assess its utility.

Rapid Access Cardiology Clinics (RACC)–Assessing Cardiovascular Risk

Background: RACC, as part of the Western Sydney Integrated Care Programme (WSICP), was established as a hospital admission diversion strategy to manage low-intermediate risk chest pain. Our objective was to examine the cardiovascular (CV) risk factor burden of patients presenting to RACC. Methods: Clinical and lifestyle risk factor data were collected for consecutive patients presenting to RACC. Results: In the first 12 months, among 520 chest pain patients (55% male, mean age 55.2 years) assessed, 12% had pre-existing coronary heart disease (CHD) and 8% were diagnosed with new CHD. Among the 414 without CHD, 89(22%) were high CV risk according to a Framingham risk calculator, 43(10%) moderate, and 282(68%) low risk. At presentation 1.7% had chronic renal failure, 22% had HbA1c ≥ 6.5%, 70% had LDL-C ≥ 2 mmol/L, 32% had SBP ≥ 140 mmHg, 79% overweight (mean BMI 29.7 ≥ 6.7 kg/m2 and mean waist circumference was 101 cm), 33% had a family history of premature CHD, and 21% were current smokers or quit within the last 12 months. Also 81% exercised below Australian Heart Foundation guidelines, 82.3% ate less than the daily recommendations of vegetables, and 49% ate less than the daily recommendations of fruit each day. Overall 81% had 2 or more CV risk factors, and the mean number of CV risk factors (diabetes, smoker, hypercholesterolaemia, hypertension, family history, CRF, known CHD, elevated waist circumference) was 2.8. Conclusions: Many patients referred to RACC with chest pain have a high burden of uncontrolled risk factors. Thus, RACCs may bring new opportunities for modifiable risk factor optimisation and cardiovascular disease prevention.

Westmead Hospital Rapid Access Cardiology Clinic (RACC)–A Year in Review

Background/Objective: RACC, as part of the Western Sydney Integrated Care Programme, was established as an alternative pathway for assessing low-intermediate risk chest pain. Our objective was to examine the implementation and utility of RACC services in its first year. Methods: Referrer, patient, and clinical data was collected between 4 Feb 2015-2016. Results: 520 patients were seen out of 864 referrals (55% male, mean age 55.2 years). 22% were seen within 2 days and 69% within 5 days. Out of the 864 referrals, 124(14%) were inappropriate (most because of very low pre-test probability or wrong indication), 153(18%) were unable to be booked (most due to difficulties contacting the patients), and 67(8%) did not attend. Of those seen, 87.2% were referred from emergency. 12% had pre-existing CHD, and 8% were diagnosed with new CHD. 175(34%) had an EST of which 11% were positive, 142(27%) had a CTCA with 17% showing obstructive CAD, 47(9%) had sestamibi with 23% positive, 23(4%) had stress echocardiograms with 17% positive, and 35(6.7%) had coronary angiograms with 51% confirming obstructive CAD. There was an average of 0.8 tests per patient. 323(62%) were discharged from RACC, 191(37%) had RACC follow-up, and 6(1%) were admitted. Out of 17 emergency referrer-satisfaction surveys completed, 7 stated they were “very satisfied” (41%), 9 were “satisfied” (53%), 1 felt “neutral” (6%) about RACC. Conclusions: RACCs are a possible alternative pathway of managing low-intermediate risk chest pain, and are well received by emergency physicians. Results indicate appropriate referrals, and judicious use of specialised cardiac testing.

12-Month Follow-up of the Rapid Access Cardiology Clinic at a Tertiary Referral Hospital

12-Month Follow-up of the Rapid Access Cardiology Clinic at a Tertiary Referral Hospital

Utility of Services and Patient Acceptability of Rapid Access Cardiology Clinic

Utility of Services and Patient Acceptability of Rapid Access Cardiology Clinic

Rapid access cardiology--a nine year review

Rapid access cardiology clinics provide a rapid assessment and evaluation of patients with suspected chest pain, heart failure or cardiac arrhythmia. Longitudinal data regarding the attendances and clinical diagnoses at rapid access clinics is lacking and may provide insight into their efficiency and role in providing a comprehensive referral service for primary care. Data regarding total number of attendances and diagnoses were retrospectively analysed from databases collated by nurse specialists and physicians undertaking rapid access clinics at Charing Cross Hospital between April 2002 and March 2011. A total of 12 000 patients were seen over the 9-year time period. Demand for Rapid Access Chest Pain Clinic and Rapid Access Arrhythmia Clinic has shown a steady rise since 2007 whereas attendances at Rapid Access Heart Failure Clinic have remained constant. The proportion of patients diagnosed with significant cardiac disease across all rapid access clinics has not changed significantly. The most commonly diagnosed arrhythmia was atrial fibrillation (15% of all attendances). Referrals have increased to our service which suggests that demand for a rapid access cardiology service remains high and the proportion of patients diagnosed with significant cardiac disease has remained constant. Despite considerable motivation towards providing primary based care this has not occurred in our local area and we believe this shows that our model, based in secondary care to be both efficient and accessible to local GPs and patients.

Improving door-to-balloon times in Asia for acute ST elevation myocardial infarction via direct activation by emergency physicians of percutaneous coronary intervention

Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. Guideline 2009;95. [5] Bourdillon P. Exercise ECG useful in finding coronary artery disease. BMJ 2010;340: c1971. [6] Underwood SR. W(h)ither the exercise ECG? BMJ 2010;340:c2387. [7] Timmis A. NICE and chest pain diagnosis. BMJ 2010;340:c2391. [8] Pryor DB, Shaw L, McCants CB, et al. Value of the history and physical in identifying patients at increased risk for coronary artery disease. Ann Intern Med 1993;118: 81–90. [9] Tenkorang JN, Fox KF,Wood DA. A brief report on the data available on rapid access cardiology clinics. Br J Cardiol 2005;12:139–41. [10] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131:149–50.

Clinical signs and symptoms of oropharyngeal aspiration and dysphagia in children

The diagnostic value of various signs and symptoms (clinical markers) in predicting oropharyngeal aspiration (OPA) or swallowing dysfunction has not been established in children. The present retrospective study was undertaken to: 1) identify specific clinical markers associated with radiographic evidence of OPA, isolated laryngeal penetration (ILP) and post-swallow residue (PSR); 2) determine the sensitivity and specificity of clinical markers associated with OPA; and 3) determine the influence of age and neurological impairment on clinical markers of OPA. In total, 11 clinical markers of dysphagia were compared with the videofluoroscopic swallow study (VFSS) results (OPA, ILP and PSR) in 150 children on diets of thin fluid and purée consistencies. Chi-squared and logistic regression were used to analyse the association between clinical markers and VFSS-identified swallowing dysfunction. In children with OPA, wet voice (odds ratio (OR) 8.90, 95% confidence interval (CI) 2.87-27.62), wet breathing (OR 3.35, 95% CI 1.09-10.28) and cough (OR 3.30, 95% CI 1.17-9.27) were significantly associated with thin fluid OPA. Predictive values included: wet voice (sensitivity 0.67; specificity 0.92); wet breathing (sensitivity 0.33; specificity 0.83); and cough (sensitivity 0.67; specificity 0.53). No clinical markers were significantly associated with OPA, ILP or PSR on the purée consistency. Cough was significantly associated with PSR on thin fluids (OR 3.59, 95% CI 1.22-10.55). Differences were found for age. Wet voice, wet breathing and cough were good clinical markers for children with oropharyngeal aspiration on thin fluid but not on purée. Age and neurological status influenced the significance of these clinical markers.

Are rapid access cardiology clinics a valued part of a district cardiology service?

Background Improved processes of referral from Primary Care are an important part of a strategy to reduce the population burden of cardiovascular disease. A unique service of rapid access clinics, where primary care practitioners can refer patients to a daily secondary care cardiology service without appointment has been established at Charing Cross Hospital in West London. Previous data have shown the effectiveness of this service in diagnosing and risk stratifying patients with suspected cardiac disease. We evaluated Primary Care and Patient views on this service. Methods A patient survey of a cohort of 1223 patients recruited to a follow up study of individuals seen over 1 year in the service and qualitative in-depth interviews of a randomised sample of 10 out of 82 referring Primary Care Practitioners was performed. Results Less than 2% of patients had a negative experience of the service. Most patients did not have to revisit the Primary Care Practitioner for the same symptom. Primary Care Practitioners were overwhelmingly positive about the ease of access. They viewed positively the ability to obtain prompt diagnosis or reassurance. The heart failure service was used least but this was the most challenging condition to diagnose. There were concerns about nurse specialist based services and restriction to ‘first presentations’. Communication about the service could be improved. Conclusions A ‘no appointment’, one stop, rapid access service for the diagnosis and risk stratification of suspected new cardiac disease is viewed very positively by patients and Primary Care Practitioners.

Rapid access cardiology services enable prompt and accurate diagnosis

Rapid access cardiology services enable prompt and accurate diagnosis