How relevant is the ISCHEMIA trial to a rapid access chest pain clinic cohort of patients?

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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Same day CT angiography in a nurse-led Rapid Access Chest Pain Clinic

European Journal of Cardiovascular Nursing ◽

10.1093/eurjcn/zvab060.122 ◽

2021 ◽

Vol 20 (Supplement_1) ◽

Author(s):

A Pottle ◽

S Deane ◽

N Dent ◽

N Mackay ◽

G Marshall ◽

...

Keyword(s):

Chest Pain ◽

Pain Clinic ◽

Recent Onset ◽

Rapid Access ◽

National Service Framework ◽

Pain Clinics ◽

Cardiac Centre ◽

Artery Disease ◽

The Uk ◽

Typical Chest Pain

Abstract Funding Acknowledgements None Background Rapid Access Chest Pain clinics (RACPCs) were established in the UK in 2000 following the publication of the National Service Framework for Coronary Heart Disease. Patients underwent an exercise test (ETT) in the clinic as part of a ‘one-stop’ protocol with follow-up only if further investigation was required. In 2010, the National Institute for Health and Care Excellence (NICE) produced guidelines for the assessment and diagnosis of chest pain of recent onset (CG95), replacing the recommendation for ETT with non-invasive functional testing for patients with an intermediate pre-test probability of coronary artery disease (CAD), necessitating multiple appointments to evaluate the patient’s symptoms. The guidelines were updated in 2016, with a new recommendation that patients with atypical or typical chest pain should undergo CT coronary angiography (CTCA) as the first diagnostic test. Purpose The aim of this study was to investigate the feasibility and potential benefit of performing same -day CTCA in the RACPC. Method From November 2016 all patients with atypical or typical chest pain attending the RACPC at this tertiary cardiac centre were referred for CTCA unless alternative investigation was clinically indicated. From February 2018, same day CTCA was offered to some patients. Up to two scans could be performed in each clinic, which was increased to up to three in June 2018. Results A total of 985 patients were seen in the nurse-led clinic between 12/02/2018 and 30/11/2019. 473 patients were referred for CTCA (48.0%) and 314 scans were carried out in the clinic (66.4%). Of those scans carried out in clinic, 128 patients had a CTCA which showed no evidence of CAD (40.8%) and 34.4% of scans showed non-obstructive CAD. In 18.2% of patients, the CTCA showed significant CAD and in 21 patients (6.7%) the scan was inconclusive. Patient with inconclusive scans underwent further testing which was negative in all cases. The outcome for patients with significant CAD (57 patients) is shown in the table. Conclusion CTCA on the same day as the RACPC appointment is feasible and facilitates rapid further investigation and treatment of patients with potentially significant CAD. It also enables patients with non-significant or no CAD to be reassured that their symptoms are unlikely to be cardiac which will reduce anxiety and allow timely investigation of other causes of the chest pain. Nurses need training in the risks of radiation in order to be able to request the scans and enable the clinic to be nurse-led.

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