Chest Pain Risk Scores Correlates with Initiation of Medical Therapy or Revascularisation Following Rapid Access Chest Pain Clinic Review

Abstract Background The ISCHEMIA trial demonstrated that optimal medical therapy (OMT) is not inferior to an early interventional approach for stable angina. This could significantly impact on clinical practice. This study aimed to check the relevance of the ISCHEMIA trial in a real-world population of patients referred to a tertiary centre with recent onset chest pain (CP). Methods In this registry study, electronic notes of all patients assessed in a Rapid Access Chest Pain Clinic (RACPC) within a 12-month period (2018–19) were reviewed. Patients were selected if they met key ISCHEMIA trial inclusion criteria. Results 2416 patients were assessed, 378 (15.6%) presented with typical anginal CP, 1357 (56.2%) had atypical CP and 681 (28.2%) had non anginal CP. Of the typical CP group, 158 patients were excluded (91 known CAD, 62 ACS, 2 eGFR <30mL/min, 3 severe LVSD). This resulted in 220 patients, representing 58.2% of the typical chest pain population and 9.1% of all patients seen in RACPC. These patients had a median age of 60 years, 96 (44%) female, 119 (54.1%) had high cholesterol, 44 (20%) had diabetes, 115 (52.3%) had hypertension, 104 (47.3%) had a family history of ischaemic heart disease, and 32 (14.5%) were current smokers. Of these 220 patients, 48 (21.8%) had a CT coronary angiogram (CTCA) requested as their first line investigation (42 completed) with 1 (2.4%) patients result suggestive of significant left main stem (LMS) disease. 15 (6.8%) patients had stress echocardiography requested as their first line investigation (13 completed), 4 (31%) were positive for inducible ischaemia. 3 (1.4%) patients had stress CMR requested as their first line investigation (2 completed), both were negative. 143 (65%) patients had an invasive coronary angiogram (ICA) requested as their first line investigation (112 completed). 8 patients had severe LMS disease and were referred for surgical opinion. A further 11 patients were referred for surgical opinion due to multivessel disease or aberrant coronary anatomy. In total 24 (21.4%) patients were treated with PCI following ICA as their first line investigation. All patients were started on medical therapy for presumed CAD with up-titration while awaiting investigations. The median wait time for a CTCA was 55 days compared to 165.5 days for ICA. Two patients (0.9%) from the cohort of 220 patients died during the follow up period, compared to 2.5% of patients admitted from RACPC with an ACS diagnosis. Conclusion Patients present with undifferentiated chest pain, consequently the outcomes of the ISCHEMIA trial must be considered cautiously. Within our cohort of 2416 patients, only 9% of patients met key inclusion criteria of the trial. Ultimately, only 19.5% patients with typical chest pain were revascularised, unlike 80% of patients in the invasive arm of ISCHEMIA. It is unclear how the results of the ISCHEMIA trial will impact on UK practice, but it is clear that OMT plays a central role. Funding Acknowledgement Type of funding source: None

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155 Evaluation of the Rapid Access Chest Pain Clinic Service

Heart ◽

10.1136/heartjnl-2015-308066.155 ◽

2015 ◽

Vol 101 (Suppl 4) ◽

pp. A89.1-A89

Author(s):

Ho Tin Wong ◽

Alexander Daniel Simms ◽

Mirza Wazir Baig ◽

Klaus Karl Witte

Keyword(s):

Chest Pain ◽

Pain Clinic ◽

Rapid Access

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An absolute risk-guided approach to cardiovascular risk management within a chest pain clinic: the ARCPAC randomized trial

European Heart Journal ◽

10.1093/ehjci/ehaa946.2916 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

J.A Black ◽

J Campbell ◽

J Sharman ◽

M Nelson ◽

S Parker ◽

...

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Cardiovascular Risk ◽

Chest Pain ◽

Smoking Status ◽

Absolute Risk ◽

Pain Clinic ◽

Risk Scores ◽

Cardiovascular Risk Management ◽

Risk Factor Management

Abstract Background The majority of patients attending chest pain clinics are found not to have a cardiac cause of their symptoms, but have a high burden of cardiovascular risk factors that may be opportunistically addressed. Absolute risk calculators are recommended to guide risk factor management, although it is uncertain to what extent these calculations may assist with patient engagement in risk factor modification. Purpose We sought to determine the usefulness of a proactive, absolute risk-based approach, to guide opportunistic cardiovascular risk factor management within a chest pain clinic. Methods This was a prospective, open-label, blinded-endpoint study in 192 enhanced risk (estimated 5-year risk ≥8%, based on Australian Absolute Risk Calculator) patients presenting to a tertiary hospital chest pain clinic. Patients were randomized to best practice usual care, or intervention with development of a proactive cardiovascular risk management strategy framed around a discussion of the individual's absolute risk. Patients found to have a cardiac cause of symptoms were excluded as they constitute a secondary prevention population. Primary outcome was 5-year absolute cardiovascular risk score at minimum 12 months follow up. Secondary outcomes were individual modifiable risk factors (lipid profile, blood pressure, smoking status). Results 192 people entered the study; 100 in the intervention arm and 92 in usual care. There was no statistical difference between the two groups' baseline sociodemographic and clinical variables. The intervention group showed greater reduction in 5-year absolute risk scores (difference −2.77; p<0.001), and more favourable individual risk factors, although only smoking status and LDL cholesterol reached statistical significance (table). Conclusion An absolute risk-guided proactive risk factor management strategy employed opportunistically in a chest pain clinic significantly improves 5-year cardiovascular risk scores. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Tasmanian Community Fund

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