Rapid Access Chest Pain Clinic Research Articles

Anomalous left anterior descending artery arising from the pulmonary trunk: a rare cause of angina

A 60-year-old man with a medical history of hypertension and dyslipidaemia presented to our rapid access chest pain clinic with a 2-month history of chest pain on exertion. An exercise...

The rapid access chest pain clinic (RACPC) and the role of the cardiac physiologist

Coronary heart disease (CHD) is one of the largest killers in the UK. Rapid access chest pain clinics (RACPCs) provide an effective and efficient method for the early diagnosis of patients with CHD. Currently, specialist nurses lead these services. However, there has been a shift, with the focus moving towards cardiac physiologists (CPs) and the role they have to play in delivering these services. The article reflects on the experiences and challenges of a CP's involvement in RACPC. Through these observations and learning points, we aim to encourage other CPs to implement comparable RACPC service delivery systems for the benefit of patients, the broader integrated workforce and the wider healthcare community.

98 Longer term outcomes of patients discharged from rapid access chest pain clinic after first consultation

IntroductionThe Rapid Access Chest Pain Clinics (RACPC) system has become an important way of assessing patients who present with chest pain to their primary care physician. Based on standard protocols...

65 Quality improvement and cost savings associated with an update to the acute chest pain pathway and introduction of 3 hour rule-out troponin assay in a busy district general hospital setting

IntroductionManagement of acute chest pain involves the urgent and careful clinical assessement of a patient, to ensure timely treatment of a potentially life-threatening heart attack and the identification of other,...

108 Clinical outcome and cost-effectiveness of performing cardiac investigations in a very low likehood of coronary artery disease population according to nice and esc risk prediction models

BackgroundThe NICE (National Institute for Health and Care Excellence) guidance for the management of recent-onset chest pain in 2010, recommended no routine cardiac investigations for patients with risk of coronary...

104 A service review and comparison of resource?utilisation with the change in recommendations from nice 2010 cg95 to the nice 2016update (chest pain of recent onset: assessment and diagnosis)

BackgroundNICE 2010 guidelines (CG95) proposed investigation according to pre-test likelihood (PTL) of coronary artery disease (CAD) in patients presenting with stable chest pain; low risk patients are referred for CT...

Nurse-led rapid-access chest pain clinics: effective, safe and here to stay

To analyse test utilisation and revascularisation rates in a large, nurse-led, rapid-access chest pain (RACP) clinic. In addition, to assess for subsequent acute coronary syndrome (ACS) presentations in patients referred with suspected stable coronary artery disease (SCAD). Retrospective analysis

Audit analysing the outcome of patients referred to the rapid-access chest pain clinic and assessing the positive predictive value of the rapid-access chest pain clinic of patients with coronary artery disease

Analyse outcomes of patients referred to the rapid-access chest pain clinic (RACPC). Identifying positive predictive rate of angiograms, highlighting patterns of referral and to examine clinical outcomes of attendants, assessing efficiency. 1,212 patients were sampled. Inclusion criteria: all

Can paramedics avoid A&E departments with patients complaining of non-traumatic chest pain?

The ‘Paramedic Pathfinder’, a triage tool for paramedics, contains a discriminator for patients complaining of non-traumatic chest pain. The pathfinder advises all patients with non-traumatic chest pain to be taken to hospital. Given a background of large numbers of patients complaining of chest pain and the policy direction of UK ambulance services to treat patients closer to home, the inclusion of discriminator in the pathfinder can be challenged. A greater understanding of ACS, university education for paramedics, bedside troponin measurement, ACS risk scoring, current NICE guidelines and rapid access chest pain clinics have been identified as enablers to remove the discriminator safely and assist paramedics in finding suitable alternatives to Accident and Emergency for certain patients. Risk is an important factor in discussing chest pain and establishing the best pathway for patients. The enablers identified need further testing and development in the pre-hospital environment before they can be utilised.

Coronary CT is Increasingly Used in a Contemporary Rapid Access Chest Pain Clinic, and Alters Management in the Majority of Patients with Coronary Disease Detected

Coronary CT is Increasingly Used in a Contemporary Rapid Access Chest Pain Clinic, and Alters Management in the Majority of Patients with Coronary Disease Detected

Initial Single Centre Experience Implementing a Rapid Access Chest Pain Clinic

Cardiac chest pain accounts for 8335 presentations to the Emergency Department at Royal North Shore Hospital (RNSH) annually and of these more than 700 are hospitalised because of intermediate risk and discharged within 1.2 days without a need for invasive investigation–a cost burden exceeding $1.5 million. A Rapid Access Chest Pain Clinic (RACPC) affords a potential mechanism of cost saving without compromise of patient safety. Aim: We report initial experiences in clinic processes, case selection, patient safety, cost analysis, outcome measures and research potential. Methods: Staff costs included 0.5 FTE advanced trainee and 0.5 FTE senior medical staff for a daily morning clinic. The Heart Score and standard NSW Chest Pain pathway were utilised to risk stratify patients. Results: 15 patients were seen in the first 4 weeks. All patients had clinical assessment. Functional tests were performed in 14 and CT coronary angiogram in 6. Four proceeded to elective angiography and 2 had culprit vessel stenting. No patient had acute myocardial infarction or urgent re-admission. 1 stented patient stayed overnight in RNSH, therefore admission was avoided in 14 patients with a potential annual saving of $68,996. Conclusion: Initial experience of managing intermediate risk patients in a RACPC shows a reduction in admitted patients, without undermining patient safety and quality of care, plus potential cost-benefit to the healthcare system with this model of care. Exploring robust methods of identifying the appropriate cohort of patients and evaluating the impact of the clinic are potential research opportunities aiming to improve on current evidence.

61 Predictive performance of heart fatty acid-binding protein (H-FABP) and highly sensitive troponin T (hsTnT) in patients with suspected coronary artery disease

Introduction Current NICE chest pain guidelines suggest coronary artery calcium scores (CACS), CT coronary angiography (CTCA), functional testing and invasive angiography depending on Diamond Forrester (DF) risk scores. Heart-type fatty acid-binding protein (H-FABP) has previously been assessed as an early ischaemic biomarker. Highly sensitive troponin T (hsTnT) is currently used for ACS diagnosis. Little work has been undertaken to assess early ischaemic biomarkers as predictors of coronary artery disease (CAD) in high risk patients following exercise stress testing (EST). Methodology We prospectively evaluated if H-FABP and hsTnT following exercise could predict a primary outcome of obstructive CAD requiring coronary stenting or bypass surgery in high risk patients recruited from the rapid access chest pain clinic. Baseline demographics, cardiac risk factors and a DF risk score were recorded. Baseline blood samples were taken at 0, 2, 4 and 6 hours for H-FABP and hsTnT after exercising on a full Bruce EST protocol (Figure 2). Invasive angiography was undertaken if this was positive for ischaemia. If the EST was negative, patients had a CACS and if this was >0 patients had follow-on CTCA. Invasive angiography was performed if this showed obstructive CAD. Results Of the 48 patients enrolled, 25 (52.1%) were male, 9 (18.8%) were smokers, 4 (8.3%) were diabetic, 31 (64.6%) had hypercholesterolaemia, 22 (45.8%) had hypertension and 33 (68.8%) had a positive family history of CAD. CAD was seen in 16 (33.3%) patients on CTCA or invasive angiography, 7 (14.6%) met primary outcome criteria (4 had coronary stenting and 3 had bypass surgery). Comparing those with and without intervention, there was no statistical difference in risk factors (p > 0.05), Table 1. Median DF score was 92% in the intervention and 92% in the non-intervention group, p = 0.82, AUC 0.53. Median CACS score was 55 versus 0 in the intervention versus non-intervention group, p = 0.27, AUC 0.72. However, median CACS was predictive of overall CAD, 122 versus 0 respectively, p ≤ 0.001, AUC 0.89. Table 2 compares median 6 hour hsTnT, H-FABP and TnI in intervention and non-intervention groups. There was no statistically significant difference in any biomarker, p > 0.05. Conclusion In this cohort there was no statistical difference in risk factors or DF risk score between the intervention and non-intervention group. CACS (leading to CTCA) was statistically associated with CAD prediction but not predictive of patients requiring intervention. H-FABP and hsTnT are early ischaemic markers but were not predictive of obstructive CAD post EST in a high risk population.

High Rates of Self-Reported Depression in a Rapid Access Chest Pain Clinic (RACPC) Population From a Tertiary Metropolitan Hospital

High Rates of Self-Reported Depression in a Rapid Access Chest Pain Clinic (RACPC) Population From a Tertiary Metropolitan Hospital

Rapid Access Chest Pain Clinic (RACPC): Utilisation and Outcomes

Rapid Access Chest Pain Clinic (RACPC): Utilisation and outcomes Introduction: Rapid access to chest pain assessment and management potentially improves patient outcomes. Fiona Stanley Hospital commenced an outpatient Rapid Access Chest Pain Clinic (RACPC) accepting referrals from general practitioners (GP) and emergency departments (ED). Referred patients are triaged and reviewed by registrars with on-site cardiologist consultation. Method: We performed a retrospective audit of patients referred to the RACPC from February 2015 to December 2015. We describe the source of referral, investigations requested and clinical outcomes. Data was collected from the digital medical records. Results: Of 503 patients referred, 56% were male and 62% were under age 65 years. GP referrals accounted for 44%, with ED accounting for 34%. The majority, 57%, of patients were intermediate risk (TIMI score of 2-4). Half of the referred patients were discharged without any invasive investigation, 24% (n=123) were referred for coronary angiogram. The remainder were referred to private cardiologists (4%), did not attend clinic appointment (6%), refused treatment or investigation (2%), were on-referred to other cardiology clinics (10%) or died (<0.5%). Of the patients referred for angiogram 10% had normal angiogram, 30% were medically managed and 60% required percutaneous intervention or coronary artery bypass grafting equating to 1 out of 8 referred patients. Conclusion: We describe the characteristics of a RACPC in a modern tertiary hospital accepting ED and GP referrals. The RACPC potentially allows for efficient outpatient workup and appropriate management avoiding ED presentation or prolonged inpatient admission.

Anatomy of a Rapid Access Chest Pain Clinic (RACPC) in a Metropolitan Tertiary Hospital Setting

Anatomy of a Rapid Access Chest Pain Clinic (RACPC) in a Metropolitan Tertiary Hospital Setting

UPBEAT-UK: a programme of research into the relationship between coronary heart disease and depression in primary care patients

BackgroundDepression is common in patients with coronary heart disease (CHD) but the relationship is uncertain. In the UK, general practitioners (GPs) have been remunerated for finding depression in CHD patients; however, it is unclear how to manage these patients.ObjectivesOur aim was to explore the relationship between CHD and depression in a GP population and to develop nurse-led personalised care (PC) for patients with CHD and depression.DesignThe UPBEAT-UK study consisted of four related studies. A cohort study of patients from CHD registers to explore the relationship between CHD and depression. A metasynthesis of relevant literature and two qualitative studies [patients’ perspectives and GP/practice nurse (PN) views on management of CHD and depression] helped develop an intervention. A pilot randomised controlled trial (RCT) of PC was conducted.SettingThirty-three GP surgeries in south London.ParticipantsAdult patients on GP CHD registers.InterventionsFrom the qualitative studies, we developed nurse-led PC, combining case management and self-management theory. Following biopsychosocial assessment, a PC plan was devised for each patient with chest pain and depressive symptoms. Nurses helped patients address their most important related problems. Use of existing resources was promoted. Nurse time was conserved through telephone follow-up.Main outcome measuresThe main outcome of the pilot study of our newly developed PC for people with depression and CHD was to assess the acceptability and feasibility of the intervention and to decide on the best outcome measures. Depression, measured by the Hospital Anxiety and Depression Scale – depression subscale, and chest pain, measured by the Rose angina questionnaire, were the main outcome measures for the feasibility and cohort studies. Cardiac outcomes in the cohort study included: attendance at rapid access chest pain clinics, stent insertion, bypass graft surgery, myocardial infarction and cardiovascular death. Service use and costs were measured and linked to quality-adjusted life-years (QALYs). Data for the pilot RCT were obtained by research assistants from patient interviews at baseline, 1, 6 and 12 months for the pilot RCT and at baseline and 6-monthly interviews for up to 36 months for the cohort study, using standard questionnaires.ResultsPersonalised care was acceptable to patients and proved feasible. The reporting of chest pain in the intervention group was half that of the control group at 6 months, and this reduction was maintained at 1 year. There was also a small improvement in self-efficacy measures in the intervention group at 12 months. Anxiety was more prevalent than depression in our CHD cohort over the 3 years. Nearly half of the cohort complained of chest pain at outset, with two-thirds of these being suggestive of angina. Baseline exertional chest pain (suggestive of angina), anxiety and depression were independent predictors of adverse cardiac outcome. Psychosocial factors predicted the continued reporting of exertional chest pain across the 3 years of follow-up. Costs were slightly lower for the PC group but QALYs were also lower. Neither difference was statistically significant.ConclusionsChest pain, anxiety, depression and social problems are common in patients on CHD registers in primary care and predict adverse cardiac outcomes. Together they pose a complex management problem for GPs and PNs. Our pilot trial of PC suggests a promising approach for treatment of these patients. Generalisation is limited because of the selection bias in recruitment of the practices and the subsequent participation rate of the CHD register patients, and the fact that the research took place in south London boroughs. Future work should explicitly explore methods for effective implementation of the intervention, including staff training needs and changes to practice.Trial registrationCurrent Controlled Trials ISRCTN21615909.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 8. See the NIHR Journals Library website for further project information.

Cardiac Computed Tomography Is Cost-Effective Compared With Exercise Stress Testing in Investigating Patients With Stable Chest Pain

Computed Tomography coronary angiography (CTCA) is a non-invasive imaging technique used to detect coronary heart disease(CHD) in patients with stable chest pain of suspected cardiac origin. Exercise electrocardiography stress test (EST) use has previously been the choice of investigation of stable chest pain in Rapid Access Chest Pain Clinics (RACPC). However studies have shown that 30% of people attending RACPC are either unsuitable for EST or achieve non-diagnostic results.1 Randomised control trials have shown cardiac CT of showing more significant disease identification and less inconclusive results when compared to EST.2 This has lead to NICE including cardiac CT in the diagnostic pathway for stable chest pain, and they have called for research on the cost-effectiveness of cardiac CT testing in the diagnosis of angina.

Changing face of the Rapid Access Chest Pain Clinic

Healthcare costs and challenges to the public and to the NHS are ongoing. Coronary heart disease (CHD) is known to affect up to 2 million people per year in the UK ( Patterson et al, 2015 ). Earlier detection via Rapid Access Chest Pain Clinics (RACPCs) and improved treatment options are helping patients to live longer. Over recent years, the National Institute for Health and Care Excellence (NICE) has released guidelines regarding the assessment and management of chest pain ( NICE, 2010 ) This article aims explores the guidelines, and examines the author's chest pain clinic and assessment of its patients, alongside the best possible way forward in light of current guidelines. This highlights a possible conflict—does the author's Trust continue what they are doing or change a proven successful service because of what is recommended in the guidelines? The most common symptom experienced by individuals with CHD is chest pain which is believed to account for up to 700 000 admissions to emergency departments (ED) annually in England and Wales alone; however, most most of these are non-cardiac ( Patterson et al, 2015 ). This represents heavy fiscal costs to the NHS in nursing and medical time ( Goodacre et al, 2005 ).

Pre-test probability risk scores and their use in contemporary management of patients with chest pain: One year stress echo cohort study.

ObjectivesTo compare how patients with chest pain would be investigated, based on the two guidelines available for UK cardiologists, on the management of patients with stable chest pain. The UK National Institute of Clinical Excellence (NICE) guideline which was published in 2010 and the European society of cardiology (ESC) guideline published in 2013. Both guidelines utilise pre-test probability risk scores, to guide the choice of investigation.DesignWe undertook a large retrospective study to investigate the outcomes of stress echocardiography.SettingA large tertiary centre in the UK in a contemporary clinical practice.ParticipantsTwo thirds of the patients in the cohort were referred from our rapid access chest pain clinics.ResultsWe found that the NICE risk score overestimates risk by 20% compared to the ESC Risk score. We also found that based on the NICE guidelines, 44% of the patients presenting with chest pain, in this cohort, would have been investigated invasively, with diagnostic coronary angiography. Using the ESC guidelines, only 0.3% of the patients would be investigated invasively.ConclusionThe large discrepancy between the two guidelines can be easily reduced if NICE adopted the ESC risk score.

A registry comparison of ESC and nice guideines 95 in the assessment of stable angina in a UK district hospital

Atherosclerosis is an important pathogensis in the stable plaque that causes stable angina. The assessment of stable angina in patients is difficult. NICE Guidelines 95 have been present since 2010 and adopt a pre-test probability score based on age, gender, risk factors and history to assess risk for significant coronary artery disease. The ESC guidelines are more recent and are based on fewer variables. We look at 1991 patients seen in the Rapid Access Chest Pain clinics and compare the 2 guidelines.