56 Clinical and financial repercussions of the march 2010 national institute for health and clinical excellence (NICE) guideline "chest pain of recent onset" on the rapid access chest pain clinic (RACPC)

The long-awaited guideline from the National Institute for Health and Clinical Excellence (NICE) for the management of chest pain of recent onset has now been published. This provides detailed recommendations for the management of patients with chest pain of possible or likely cardiac origin. This clarity should be welcomed by Acute Physicians who have seen a significant increase in emergency referrals to hospital, of which up to 25% in our practice are patients with chest pain. The guidance aims to help and support healthcare professionals to direct their patients into the appropriate referral stream.

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

Echo Research and Practice ◽

10.1530/erp-14-0110 ◽

2015 ◽

Vol 2 (2) ◽

pp. 41-48 ◽

Cited By ~ 6

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.

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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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