128 MORE DISCHARGES, LESS FOLLOW-UP AND SIMILAR RATES OF CORONARY ANGIOGRAPHY: INITIAL ‘REAL-WORLD’ EXPERIENCE OF NICE GUIDANCE ON ASSESSMENT OF CHEST PAIN OF RECENT ONSET IN THE RAPID ACCESS CHEST PAIN CLINIC

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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A nurse-led rapid access chest pain clinic post NICE guidance: Analysis of audit results

British Journal of Cardiac Nursing ◽

10.12968/bjca.2012.7.5.236 ◽

2012 ◽

Vol 7 (5) ◽

pp. 236-241 ◽

Cited By ~ 2

Author(s):

Gemma Robson

Keyword(s):

Chest Pain ◽

Pain Clinic ◽

Rapid Access ◽

Nice Guidance

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Prognostic value of demographic factors, pre-test probability scoring, exercise test diagnosis, and inability to exercise in patients with recent onset suspected cardiac chest pain

European Journal of Preventive Cardiology ◽

10.1177/1741826711404505 ◽

2011 ◽

Vol 19 (3) ◽

pp. 419-427 ◽

Cited By ~ 3

Author(s):

Rajdeep S Khattar ◽

Satheesh B Nair ◽

Tahir Hamid ◽

Sanoj Chacko ◽

Mamas Mamas ◽

...

Keyword(s):

Chest Pain ◽

Exercise Test ◽

Prognostic Value ◽

Pain Clinic ◽

Family Practitioner ◽

Recent Onset ◽

Coronary Syndrome ◽

Exercise Ecg ◽

Test Probability

Aims: To assess the prognostic value of an inconclusive exercise test or inability to exercise in patients with recent onset suspected cardiac chest pain and to determine the independent predictors of events in these patients. Methods: This was an observational follow-up study of patients presenting to a rapid access chest pain clinic with a history of recent-onset suspected cardiac chest pain as referred by the family practitioner. The main outcome measure was a composite endpoint of death and acute coronary syndrome hospital admission. Results: The study cohort consisted of 1851 patients in whom a total of 147 events were recorded during a mean follow-up period of 4.1 ± 1.1 years. Those with events were significantly older (65.1 ± 12.5 years versus 56.4 ± 13.2 years, p < 0.001), had higher mean pre-test probability of coronary artery disease (CAD), and had higher prevalence of diabetes (18.4% vs. 13.6%, p < 0.001), hypertension (55.8% vs. 38.7%, p < 0.001), and smoking (36.7% vs. 25.4%, p = 0.03) than those without events. These patients were also more likely to have a positive exercise electrocardiogram (ECG) (15.6% vs. 8.6%, p < 0.001) or not have a diagnostic exercise test because of an inconclusive result or inability to exercise (60.5% vs. 28.6%, p < 0.001). Cox multivariate regression analysis showed that age (hazard ratio, HR 1.03, p < 0.001), pre-test probability of CAD (HR 1.08, p = 0.04), positive exercise ECG (HR 2.94, p < 0.001), and an inconclusive test or inability to exercise (HR 3.45, p < 0.001) were independent predictors of events. Conclusions: In patients with recent onset suspected cardiac chest pain, not having a diagnostic exercise ECG because of an inconclusive test or inability to exercise is an independent predictor of events and has similar prognostic implications to a positive exercise ECG. In addition, pre-test probability estimation at baseline is a robust indicator of clinical outcome. Future models of care need to incorporate early and increased access to non-exercise cardiac imaging techniques in order to meet the needs of this high-risk subgroup of patients.

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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)

Heart ◽

10.1136/heartjnl-2011-300198.56 ◽

2011 ◽

Vol 97 (Suppl 1) ◽

pp. A36-A36

Author(s):

T. Rogers ◽

S. Claridge ◽

K. Al Fakih

Keyword(s):

Chest Pain ◽

Clinical Excellence ◽

Pain Clinic ◽

Recent Onset ◽

Nice Guideline ◽

Rapid Access

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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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Downstream testing after CT coronary angiography: time for a rethink?

Open Heart ◽

10.1136/openhrt-2021-001597 ◽

2021 ◽

Vol 8 (1) ◽

pp. e001597

Author(s):

Gareth Morgan-Hughes ◽

Michelle Claire Williams ◽

Margaret Loudon ◽

Carl A Roobottom ◽

Alice Veitch ◽

...

Keyword(s):

Coronary Artery Disease ◽

Chest Pain ◽

Coronary Artery ◽

Coronary Angiography ◽

Communication Systems ◽

Ct Coronary Angiography ◽

Second Line ◽

Recent Onset ◽

Line Test ◽

Artery Disease

ObjectiveWe surveyed UK practice and compliance with the National Institute for Health and Care Excellence (NICE) ‘recent-onset chest pain’ guidance (Clinical Guideline 95, 2016) as a service quality initiative. We aimed to evaluate the diagnostic utility and efficacy of CT coronary angiography (CTCA), NICE-guided investigation compliance, invasive coronary angiography (ICA) use and revascularisation.MethodsA prospective analysis was conducted in nine UK centres between January 2018 and March 2020. The reporter decided whether the CTCA was diagnostic. Coronary artery disease was recorded with the Coronary Artery Disease–Reporting and Data System (CAD-RADS). Local electronic records and picture archiving/communication systems were used to collect data regarding functional testing, ICA and revascularisation. Duplication of coronary angiography without revascularisation was taken as a surrogate for ICA overuse.Results5293 patients (mean age, 57±12 years; body mass index, 29±6 kg/m²; 50% men) underwent CTCA, with a 96% diagnostic scan rate. 618 (12%) underwent ICA, of which 48% (298/618) did not receive revascularisation. 3886 (73%) had CAD-RADS 0–2, with 1% (35/3886) undergoing ICA, of which 94% (33/35) received ICA as a second-line test. 547 (10%) had CAD-RADS 3, with 23% (125/547) undergoing ICA, of which 88% (110/125) chose ICA as a second-line test, with 26% (33/125) leading to revascularisation. For 552 (10%) CAD-RADS 4 and 91 (2%) CAD-RADS 5 patients, ICA revascularisation rates were 64% (221/345) and 74% (46/62), respectively.ConclusionsWhile CTCA for recent-onset chest pain assessment has been shown to be a robust test, which negates the need for further investigation in three-quarters of patients, subsequent ICA overuse remains with almost half of these procedures not leading to revascularisation.

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