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

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.

A Nurse-Led Rapid Access Chest Pain Clinic—Experience from the First 3 Years

2005 ◽  
Vol 4 (3) ◽  
pp. 227-233 ◽  
Author(s):  
Alison Pottle
Keyword(s):  
Coronary Heart Disease ◽  
Heart Disease ◽  
Chest Pain ◽  
Pain Clinic ◽  
National Service ◽  
Rapid Access ◽  
Nurse Consultant ◽  
National Service Framework ◽  
Pain Clinics ◽  
Service Framework

Background: The clinical presentation of chest pain is a major problem for primary health care professionals. Rapid access chest pain clinics (RACPC) enable quick assessment, investigation and formation of a treatment plan for such patients without a waiting list. There has been a chest pain clinic in operation at Harefield Hospital since 1988. Until 2001, the cardiology registrars were responsible for the clinic. Beginning in January 2001, the management of the clinic was taken over by the Cardiology Nurse Consultant. This paper will describe the organisation and outcomes of the first 3 years of this nurse-run RACPC. Process: Patients are seen within 2 weeks of referral in line with the National Service Framework for Coronary Heart Disease [Department of Health. National service framework for coronary heart disease. Dept of Health; 2000. London.]. An electrocardiogram (ECG) is recorded on arrival in the clinic and the Nurse Consultant then examines the patients and decides if further investigation is required. Analysis of Results: Four hundred and fifty-four patients were seen in the clinic from January 2001–December 2003. Three hundred and twenty-four patients (71.4%) underwent exercise testing of which 54 (16.7%) had a positive result. One hundred and thirteen patients (24.9%) were referred for angiography. Of these, 75 (66.4%) had coronary heart disease. Thirty-three patients (29.2%) have undergone percutaneous coronary intervention (PCI) and 19 (16.8%) have required coronary artery bypass grafting (CABG). Twenty-three patients (20.4%) are being treated medically. Satisfaction with the service offered by the clinic was high, evidenced by the results of questionnaires sent to patients. Conclusion: This paper demonstrates that nurses can successfully run RACPCs without an increased risk of incorrect diagnosis. These clinics offer patients timely access to assessment of their chest pain and facilitate early diagnosis of cardiac disease. They are also well accepted by the patients attending the clinic.

Clinical outcomes when applying NICE guidance for the investigation of recent-onset chest pain to a rapid-access chest pain clinic population

Heart ◽  
2014 ◽  
Vol 101 (2) ◽  
pp. 113-118 ◽  
Author(s):  
Caroline Marie Patterson ◽  
Arjun Nair ◽  
Nabeel Ahmed ◽  
Leoni Bryan ◽  
Derek Bell ◽  
...  
Keyword(s):  
Chest Pain ◽  
Clinical Outcomes ◽  
Pain Clinic ◽  
Recent Onset ◽  
Rapid Access ◽  
Nice Guidance ◽  
Clinic Population

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

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
G.M Connolly ◽  
J Mora ◽  
E Sammut ◽  
M Kashyap ◽  
A Dastidar ◽  
...  
Keyword(s):  
Chest Pain ◽  
Medical Therapy ◽  
Wait Time ◽  
Pain Clinic ◽  
World Population ◽  
Coronary Angiogram ◽  
Inclusion Criteria ◽  
First Line ◽  
Rapid Access ◽  
Typical Chest Pain

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

scholarly journals What's the risk? Assessment of patients with stable chest pain

2015 ◽  
Vol 2 (2) ◽  
pp. 41-48 ◽  
Author(s):  
Arzu Cubukcu ◽  
Ian Murray ◽  
Simon Anderson
Keyword(s):  
Chest Pain ◽  
Stress Echocardiography ◽  
Clinical Excellence ◽  
Pain Clinic ◽  
Recent Onset ◽  
High Negative Predictive Value ◽  
Estimated Risk ◽  
Artery Disease ◽  
Stable Chest Pain ◽  
The Impact

In 2010, the National Institute for Heath and Clinical Excellence published guidelines for the management of stable chest pain of recent onset. Implementation has occurred to various degrees throughout the NHS; however, its effectiveness has yet to be proved. A retrospective study was undertaken to assess the impact and relevance of this guideline, comparing the estimated risk of coronary artery disease (CAD) with angiographic outcomes. Findings were compared with the recently published equivalent European guideline. A total of 457 patients who attended a Rapid Access Chest Pain Clinic were retrospectively reviewed. CAD risk was assessed according to NICE guidelines and patients were separated into typical, atypical and non-anginal chest pain groups. Risk stratification using typicality of symptoms in conjunction with NICE risk scoring and exercise tolerance testing was used to determine the best clinical course for each patient. The results include non-anginal chest pain – 92% discharged without needing further testing; atypical angina – 15% discharged, 40% referred for stress echocardiography, 35% referred for angiogram and significant CAD revealed in 8%; typical angina – 4% discharged, 19% referred for stress echocardiography, 71% referred for angiogram and 40% demonstrated CAD. Both guidelines appear to overestimate the risk of CAD leading to an excessive number of coronary angiograms being undertaken to investigate patients with typical or atypical sounding angina, with a low pick up rate of CAD. Given the high negative predictive value of stress echocardiography and the confidence this brings, there is much scope for expanding its use and potentially reduce the numbers going for invasive angiography.

scholarly journals Does stress echocardiography still have a role in the rapid access chest pain clinic post NICE CG95?

2019 ◽  
Vol 6 (2) ◽  
pp. 17-23 ◽  
Author(s):  
Victoria Pettemerides ◽  
Thomas Turner ◽  
Conor Steele ◽  
Anita Macnab
Keyword(s):  
Coronary Artery Disease ◽  
Chest Pain ◽  
Coronary Artery ◽  
Cardiac Death ◽  
Stress Echocardiography ◽  
Left Ventricular ◽  
Pain Clinic ◽  
Major Adverse Cardiovascular Events ◽  
Rapid Access ◽  
Artery Disease

Introduction The 2016 NICE clinical guideline 95 (CG95) demoted functional imaging to a second-line test following computed tomography coronary angiography (CTCA). Many cardiac CT services in the UK require substantial investment and growth to implement this. Chest pain services like ours are likely to continue to use stress testing for the foreseeable future. We share service evaluation data from our department to show that a negative stress echocardiogram can continue to be used for chest pain assessment. Methods 1815 patients were referred to rapid access chest pain clinic (RACPC) between June 2013 and March 2015. 802 patients had stress echocardiography as the initial investigation. 446 patients had normal resting left ventricular (LV) systolic function and a negative stress echocardiogram. At least 24 months after discharge, a survey was carried out to detect major adverse cardiovascular events (MACE) (cardiac death, myocardial infarction, admission to hospital for heart failure or angina, coronary artery disease at angiography, revascularisation by angioplasty or coronary artery bypass grafting) within 2 years. Results Overall, 351 patients were successfully followed up. The mean Diamond-Forrester (D-F) score and QRISK2 suggested a high pre-test probability (PTP) of coronary artery disease (CAD). There were nine deaths (eight non-cardiac deaths and one cardiac death). MACE occurred in four patients with a mean time of 17.5 months (11.6–23.7 months). The annual event rate was 0.6%. Conclusion A negative stress echocardiogram can reliably reassure patients and clinicians even in high PTP populations with suspected stable angina. It can continue to be used to assess stable chest pain post CG95.

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