This site is intended for health professionals only

The NSF on CHD: the rapid-access chest pain clinic

Carol Clapham
RGN MSc BSc
Nurse Practitioner
The Health Station
Private Medical Clinic
Hitchin, Herts
Practice Nurse
Knebworth Surgery
Herts
Cardiology Specialist Nurse
E&N Herts NHS Trust
E:carol.clapham@ntlworld.com

Coronary heart disease (CHD) is common, frequently fatal and largely preventable. The Department of Health's National Service Framework (NSF) has stated that people with symptoms of angina or suspected angina should receive appropriate investigation and treatment to relieve their pain and reduce their risk of coronary events.(1) To achieve this the NSF recommended the establishment in the UK of 50 rapid-access chest pain clinics (RACPCs) by April 2001, and 100 by April 2002, with nationwide rollout thereafter. This would ensure that people who develop new symptoms that may be due to angina can be assessed by a specialist within two weeks of referral.

[[nip6_box1_19]]

Angina
Classically angina is experienced as central chest pain due to a reduction in coronary perfusion caused by chronic stenosing atherosclerosis.(2) Each year more than 20,000 people are diagnosed with angina for the first time.(1)

Why RACPCs are needed
Emergency medical admissions continue to rise year after year, affecting resources and disrupting NHS activities.(3) Patients with acute central chest pain currently account for 20 of emergency medical admissions; however, many of these could be safely managed without admission.(4-6) Fewer than half of those admitted will have a diagnosis of acute myocardial infarction (MI) or unstable angina.(6) RACPCs can reduce hospital admissions by 20-80%.(4)
The RACPC team can receive referrals of suspected angina from a variety of sources. Accident and emergency (A&E) can refer patients after eliminating the possibility of acute coronary syndromes such as MI or unstable angina. Patients with chest pain of believed cardiac origin can then be referred to the RACPC for diagnosis. The RACPC team can also receive similar referrals directly from GPs, outpatients and hospital wards.
At the RACPC, patients take an exercise tolerance test (ETT) that enables risk stratification based upon evidence-based management.(7) The best way of achieving the NSF targets while avoiding admission is by assessment and management within the RACPC. This has been proven cost-effective and in the patient's best interests. Appropriate investigation of stable angina will identify the aetiology, estimate cardiac risk and assess the benefits of cardiac revascularisation. Interventions should relieve symptoms, and education should reduce cardiac risks and include recognition and management of symptoms.

Benefits of the RACPC

  • Quick assessment and investigation. The RACPC acts as a one-stop clinic.
  • The patient is seen by a specialist cardiology team.
  • Avoidance of admission.
  • A diagnosis is given on the same day in the majority of cases.
  • The patient receives in depth education on lifestyle and risk factor modification.
  • The patient is given advice on symptom recognition and management.
  • Treatment is initiated with minimum delay.
  • There is rapid referral for revascularisation where appropriate.

Aims of the RACPC
RACPCs have been established to enable urgent assessment of patients with possible angina, assisting GPs when they are uncertain of the diagnosis. Patients with symptoms of an MI should be referred to A&E in the usual way. Clinics will vary across the country and are run by a variety of staff, including consultants, registrars, staff-grade doctors, nurses and technicians. Many clinics are nurse-led.
The criteria for referral to the RACPC are generally restricted to:

  • Recent onset of chest pain within the last 2 weeks.
  • New chest pain - no previous history of CHD.
  • Age limits are set to men over 30 and women over 40.

All patients have a full assessment, including symptom history, past medical history, family history and current medication (see Table 1). An examination is performed looking at blood pressure (BP), pulse, body mass index, chest auscultation, checking carotid and pedal pulses and circulation. During assessment, signs of hyperlipidaemia such as corneal arcus and xanthelasma are noted, as are signs of breathlessness and anaemia, as these can assist the practitioner in determining the source of chest pain. Key investigations are shown in Table 2.

[[NIP06_table1_20]]

[[NIP06_table2_21]]

[[NIP06_table3_21]]

Risk stratification
A positive ETT, especially at a low workload, implies an increased risk of the chest pain being caused by coronary artery disease and can help to group patients prognostically and identify patients requiring urgent angiography and revascularisation.(8) The Duke treadmill score (DTS) is an index that was designed to provide survival estimates based on results from the ETT.(9) The composite DTS provides accurate diagnostic and prognostic information for the evaluation of symptomatic patients with clinically suspected ischaemic heart disease.(10) One major advantage of the ETT is that it is a noninvasive method of stratifying risk, showing the degree of reversible ischaemia.(8)

Key interventions for patients diagnosed with angina

  • Address modifiable risk factors: healthy diet and lifestyle, including activity levels, weight, alcohol, diabetes and smoking.
  • Management of hypertension. The Hypertension Optimal Treatment (HOT) Study found that the risk of CHD is directly related to both systolic and diastolic BP levels, with 14% of deaths from CHD in men and 12% in women due to raised BP (>140/90mmHg).(11) Patients with treated BP still continue to die prematurely due to inadequacy of BP control, and the British Hypertension Society recommends treatment of all patients with a CHD 10-year risk greater than 15% or where target-organ damage has occurred (ie, retinopathy, nephropathy, left ventricular hypertrophy or ischaemic heart disease).(12)
  • Low-dose aspirin, 75mg daily.(1)
  • Statins and dietary advice to reduce cholesterol to below 5mmol/l and low-density lipoprotein below 3mmol/l or by 30% (whichever is greater).(1)
  • Drug treatment to relieve symptoms - nitrates, b-blockers and calcium antagonists.(1)
  • Education regarding symptom recognition and management, such as the use of glyceryl trinitrate and when to call 999.

Primary prevention
Should the practitioner initiate pharmacological therapy in patients that are not diagnosed with angina but have considerable risk factors for CHD development?
The Joint British Recommendations on Prevention of CHD state that it is considered justified to introduce drug therapy for patients who have an absolute risk of 15% or more of developing CHD or a cardiovascular risk greater than 20% over the next 10 years:(13) "As a minimum those with an absolute CHD risk greater than 30% over ten years should be targeted and treated."

Conclusion
Patients attending RACPCs will have their chest pain investigated and assessed, resulting in reassurance for those at low risk of CHD and rapid intervention and treatment for those at high risk. Patients whose chest pain is not thought to be cardiac in origin still need to be followed up by their GP to exclude other causes. Likewise, once patients have attended the RACPC and have been diagnosed with angina or CHD they will also require follow-up and monitoring in the surgery. All primary care staff need to be aware of the RACPCs in their area and how and when to access them. There is a need for more integration of care and closer liaison between primary and secondary care, which may be partially achieved by educating health professionals about RACPCs and chest pain management strategies, to provide the patient with the best possible care.

References

  1. Department of Health. National Service Framework for coronary heart disease. London: HMSO; 2000.
  2. Cramer D. Endothelial injury and coronary artery disease. Australas J Emerg Care 1997;4(3).
  3. Capewell S. The continuing rise in emergency admissions: explanations and responses must be properly evaluated. BMJ 1996;312:991-2.
  4. Capewell S, McMurray J. Chest pain  please admit (Editorial). BMJ 2000;320(7240):951-2.
  5. Kendrick S, Frame S, Povey C. Beds occupied by emergency patients: long term trends in patterns of short term fluctuations in Scotland. Health Bull 1997;55:167-75.
  6. Blatchford O, Capewell S. Emergency medical admissions in Glasgow: general practices vary despite adjustments for age, sex and deprivation. Br J Gen Pract 1999;49:551-4.
  7. Davie AP, Caesar D, Caruana L, et al. Outcome from a rapid assessment chest pain clinic: closing Pandora's box? QJM 1998;87:494-500.
  8. Jain D, Fluck D, Sayer RW, Ray S, Paul EA, Timmis AD. Ability of a one-stop chest pain clinic to identify patients with high cardiac risk seen in a district general hospital. J R Coll Physicians Lond 1997;31:401-4.
  9. Kwok J, Minn R, Miller T. Exercise treadmill score effective in measuring subsequent cardiac risk. JAMA 1999;281:1047-53.
  10. Shaw LJ, Peterson ED, Shaw LK, et al. Use of a prognostic treadmill score in identifying diagnostic coronary disease subgroups. Circulation 1998;98(16):1622-30.
  11. Hanson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood pressure lowering and low dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment randomised trial. Lancet 1998;351:1755-62.
  12. Ramsey LE, Williams B, Johnstone GD, et al. Guidelines for management of hypertension: report of the third working party of the British Hypertension Society. J Hum Hypertension 1999;17:151-83.
  13. Wood D, Durrington P, McInnes G, Poulter N, et al. Joint British recommendations on prevention of coronary heart disease in clinical practice. Heart 1998;80 Suppl II.

Resources
National Service Frameworks
W:www.doh.gov.uk/nsf
Cochrane Heart Group
W:www.epi.bris.ac.uk/cochrane/heart.htm
European Society of Cardiology
W:www.escardio.org
Heart online
W:http://heart.bmjjournals.com