Q J Med 2001; 94: 679-686
© 2001 Association of Physicians
Suspected angina pectoris: a rapid-access chest pain clinic
From the Regional Medical Cardiology Centre, and 1 Department of Clinical Biochemistry, Royal Victoria Hospital, Belfast, UK
Received 6 September 2001 and in revised form 3 October 2001
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Summary |
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We prospectively evaluated a rapid-access chest pain clinic in terms of clinical diagnoses, outcomes, morbidity and mortality at 3 months follow-up in patients, and cost-effectiveness. All patients seen at the clinic from February 1999 to December 2000 were assessed. Referring doctors indicated the management they would have provided had the clinic been unavailable, to allow a cost-effectiveness analysis. Overall, 709 patients were referred, 471 (66%) from General Practitioners, 212 (30%) from Accident and Emergency doctors and 26 (4%) from other sources. All had recent onset, or increasing frequency of ischaemic-type chest pain (excluding those with suspected myocardial infarction or rest chest pain angina). Fifty-one (7%) had acute coronary syndromes, 119 (17%) had stable ischaemic heart disease, 144 (20%) had possible ischaemic heart disease, and 395 (56%) were considered to have non-ischaemic symptoms. Some 70% of patients were seen within 24 h. Only 57 patients (8%) were admitted. Had the clinic been unavailable, 160 patients would have been admitted. Out-patient cardiology appointments were arranged for 116 patients (16%), and 429 patients (60%) were discharged directly. Follow-up data at 3 months were obtained from 565/567 eligible patients (99.6%). No major cardiac events (death/myocardial infarction) occurred in those with non-ischaemic chest pain. There were five deaths (including one due to cancer) and three patients had a myocardial infarction (event rate 1%). There were eleven readmissions for angina: six were in patients with acute coronary syndromes, and four of these six were awaiting revascularization. The estimated net saving was £58/patient. A rapid-access chest pain clinic offers a prompt, safe and cost-effective service in a challenging group of patients.
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Introduction |
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Patients presenting with chest pain are a major problem for primary health care professionals. It is estimated that for a practice of 2500, a General Practitioner may see approximately 100 patients with chest pain every year.1 General Practitioners for the most part rely on clinical history and examination to discern non-cardiac chest pain from coronary disease. Many practices now have facilities for ECG recording or open access to a nearby hospital. However the ECG alone may provide a specific diagnosis in approximately 5% only of patients presenting with chest pain.2
Patients with ST-elevation myocardial infarction and those with unstable angina and ST-segment depression on the ECG should be referred for immediate hospitalization and treatment. However decision-making in patients with possible angina in the presence of normal or non-diagnostic ECGs, including bundle branch block, paced rhythm and chamber hypertrophy, still remains a challenge.
Those presenting with classic ischaemic-type chest pain at rest should be referred for immediate hospital care irrespective of ECG changes. However patients with acute coronary syndromes may have an atypical presentation that is not diagnosed from history, physical examination and ECG.2
Rapid-access chest pain clinics run by specifically trained staff have been shown to be a reliable and safe approach in the evaluation, triage and management of patients with suspected cardiac symptoms.1,3–8 The evidence from these clinics has been enough to persuade the health authorities to introduce this new service in UK.9 Previous studies of rapid access chest pain clinics have used the electrocardiogram and exercise stress test for risk stratification.3,4 Over the last decade, new and more promising techniques to detect myocardial necrosis have become available, which has made early risk stratification more effective.10,11 Raised concentrations of cardiac Troponin T (cTnT) or Troponin I (cTnI) are diagnostic of myocardial necrosis and strongly associated with increased risk of subsequent death or myocardial infarction.12,13 They have also been shown to be valuable markers in patients presenting with chest pain and non-diagnostic ECGs.14
The aim of this study was therefore to evaluate prospectively a rapid-access chest pain clinic that used clinical data, electrocardiogram, new cardiac markers and stress testing with or without perfusion imaging, in terms of clinical outcomes and cost-effectiveness.
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Methods |
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A rapid-access chest pain clinic has been operational in the Royal Victoria Hospital, Belfast since 22 February 1999. To ensure that the clinic was not overwhelmed by requests, referrals were invited initially from General Practitioners of North and West Belfast, but thereafter from the whole of the Greater Belfast area (population 600 000) and from our own Accident & Emergency department. Both groups of doctors were invited to refer patients with recent onset, or increasing frequency of ischaemic-sounding chest pain but specifically not those with rest chest pain, particularly those suspected with myocardial infarction or unstable angina. Referring doctors were asked to provide an alternate or default management had the clinic not been available. Calls were received via a dedicated phone or fax line, e-mail or letter, with the majority of patients (70%) seen on the day of receipt of referral or on the next working day.
The clinic operates from 0900 h to 1700 h Monday to Friday and is staffed by a staff-grade cardiologist and a clinic secretary. Consultant opinion is available if required. All patients have a consultation, clinical examination, resting 12-lead electrocardiogram, and blood drawn for lipid profile, blood sugar and markers of acute myocardial necrosis (CK and CKMB activity, Myoglobin, cTnI and/or cTnT). Point-of-care testing was used for semi-quantitative determination of cTnT and myoglobin (Roche-Boehringer Mannheim) and cTnT values of 
0.1 µg/l were taken as significant (lower detection limit 0.05 µg/l). Troponin I and myoglobin were measured in the laboratory using a Dade-Behring analyser, and values >0.99 µg/l and 92 µg/l, respectively, were considered abnormal (cTnI lower detection limit 0.02 µg/l). If the patient presented less than 12 h from the onset of symptoms and the initial tests were negative, cTnT/cTnI was repeated at least 12 h from the onset of symptoms.
Following these investigations, patients are either admitted or undergo exercise stress testing. Where appropriate, pharmacological stress testing or myocardial perfusion imaging is done. The clinic doctor, with the help of technical staff, performs all stress tests. The same day, with secretarial assistance, a short standardized report detailing the investigations results, suspected or definite diagnosis, pending investigations, outline of suggested treatment and subsequent follow-up are faxed or mailed to the General Practitioner or referring doctor. For patients who are not admitted and depending on the results of the exercise stress testing or perfusion imaging, follow-up cardiology out-patient appointments are arranged with a view to further investigations such as coronary angiography. Patients are contacted at 3 months by postal questionnaire or telephone for information on any subsequent ischaemic events or hospital admissions since attendance at the clinic.
Definitions
Based on the clinical and investigative findings patients are classified as follows (Figure 1
):
- 1. Acute coronary syndromes or high-risk ischaemic heart disease, (positive cardiac troponin or suggestive history and strongly positive stress test, i.e. ST elevation or 3 mm ST depression in limb or chest leads).
- 2. Stable ischaemic heart disease, (negative cardiac troponin, suggestive history without rest pain or absence of strongly positive stress test, i.e. <3 mm ST segment alteration).
- 3. Possible ischaemic heart disease, (negative cardiac troponin, suggestive history and negative or inconclusive stress test, i.e. no ST change, with/without chest pain and failure to achieve target heart rate, or uninterpretable, e.g. left ventricular hypertrophy, left bundle branch block, paced rhythm).
- 4. Non-ischaemic chest pain, (atypical history and negative markers and negative stress test, i.e. no ST change, no chest pain at good level of exercise).
- 2. Stable ischaemic heart disease, (negative cardiac troponin, suggestive history without rest pain or absence of strongly positive stress test, i.e. <3 mm ST segment alteration).
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Results |
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Over a period of 22 months (22 February 1999 to December 2000), 709 patients with a mean (SD) age of 53 (13) years were referred: 471 (66%) by General Practitioners, 212 (30%) from the Accident & Emergency department and 26 (4%) from other sources. Of these 709, 401 (57%) were male, 556 (78%) had a normal initial ECG, 429 (61%) had a family history of ischaemic heart disease and 252 (36%) were current smokers. Only 124 (18%) had a previous history of ischaemic heart disease (Table 1
). At presentation, 29% were on aspirin and 18% were on beta-blockers. Figure 2 shows the referral pattern over the 22 months. The mean (SD) duration of symptoms before referral was 9.0 (19.5) weeks. Average (SD) time from referral to clinic appointment was 2.04 (5.6) days, with 70% of patients seen within 24 h of the call.
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Clinic diagnosis (Table 2
)Fifty-one patients (7%) were diagnosed as having acute coronary syndromes. Of the remaining patients, stable ischaemic heart disease was diagnosed in 119 (17%), possible ischaemic heart disease in 144 (20%), and in 395 (56%) patients the cause of chest pain was thought to be non-ischaemic.
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Patient outcome
Of the 709 patients, 57 (8%) had same-day admission: 52 to the cardiology ward (51 patients with acute coronary syndromes, one patient with positive myoglobin but subsequent cardiac troponins and ECGs normal). Five patients were admitted to general medical wards with diagnoses of pulmonary embolus, respiratory tract infection/pneumonia (two patients), pleural effusion and atrial fibrillation.
Of these 51 high-risk patients with acute coronary syndromes (49% of whom were referred to the clinic directly by their General Practitioners), 49 (96%) underwent coronary angiography during their initial hospitalization. In the remaining two, symptoms settled with increased medication and they are under consideration for out-patient cardiac catheterization. Thirty-nine (76%) were referred for in-hospital revascularization, which was performed as percutaneous coronary intervention in 27 patients and coronary artery bypass grafts in 12.
Out-patient cardiology appointments were arranged for 116 (16%) patients, and 429 (60%) patients were discharged back to the General Practitioner or home directly from the clinic (Figure 3). The remaining 107 patients (15%) are awaiting further investigations such as perfusion imaging.
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A default management plan from the referring doctors was available for 671 (95%) patients (Figure 3
). If the clinic had not been available, 160 (24%) patients would have been admitted directly, compared to 57 (8%) actual admissions.
Follow-up
At three-month follow-up for serious adverse events (death or myocardial infarction) and readmissions with angina, 567/709 patients were eligible, of whom two could not be traced. Thus 565 (99.6%) completed review. In the acute coronary syndromes group of patients, there were two deaths, one an in-hospital arrest in a patient with significant left main-stem and triple-vessel disease awaiting coronary artery bypass grafting, and one following coronary artery bypass grafts (a 77-year-old man who developed ventricular fibrillation 4 days after satisfactory coronary artery bypass grafting with subsequent haemodynamic deterioration and death 19 days after coronary artery bypass grafting). In the stable ischaemic heart disease group, there was one sudden death in an 82-year-old female whose troponins had been negative and who had achieved 6 min on the Bruce protocol with only 1.5 mm horizontal ST depression in leads V5, V6. In the possible ischaemic heart disease group, there was also one sudden death in a 76-year-old female whose troponins had been negative, no ECG changes or chest pain after 6.5 min on the modified Bruce protocol. Both of these latter deaths occurred approximately 1 month after the clinic visit. One patient died from cancer in the possible ischaemic heart disease group.
In the stable ischaemic heart disease group, one patient developed a non-Q-wave myocardial infarction. In the possible ischaemic heart disease group, two patients developed myocardial infarctions, at 5 and 6 weeks respectively, while awaiting myocardial perfusion scans. No major cardiac events (death or myocardial infarction) occurred in patients diagnosed with non-ischaemic chest pain.
There were 11 readmissions for angina. Six were patients initially diagnosed as acute coronary syndromes and four of these six were awaiting revascularization. In the remaining two, one patient had percutaneous coronary intervention during the initial admission and a subsequent exercise stress test did not show any significant change, and the other patient was an 82-year-old managed medically. There were four readmissions in the stable ischaemic heart disease group, two while awaiting out-patient appointments. The remaining two patients from the stable ischaemic heart disease group and one patient in the possible ischaemic heart disease group who were readmitted were initially referred back to their General Practitioner. None of the patients diagnosed as non-ischaemic chest pain were readmitted.
A cost-effectiveness analysis was done (Table 3). All expenses involved in the day-to-day running of the clinic were calculated. Using the default management, this was compared against the potential costs associated with the presumed management of patients in the absence of the clinic. Previous studies have shown that hospital stay for a chest pain patient in UK can vary from 2–5 days with an average of 3 days. Based on a 72-h stay, there was a net saving of £41332 for 709 patients seen at the rapid-access chest pain clinic. However if the patient stayed 48 h, and calculating for two sets of cardiac enzymes and stress testing then the net saving would be £15530 for 709 patients, or £22 per patient seen.
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Discussion |
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Our study confirms that a rapid-access chest pain clinic can reliably identify high-risk patients whilst significantly reducing the number of unnecessary hospital admissions. These findings are consistent with previous studies, thus clearly demonstrating the role of rapid-access chest pain clinics in the management of this difficult subset of patients.3–6 Risk stratification in this study was performed using clinical and currently available evidence-based investigations.
Although this was not a randomized trial, all referring doctors were asked to provide prospectively, in writing, a default management plan had the clinic not been available. A significant reduction was seen in the actual admission rate compared to the default management (57 vs. 160 patients, respectively). At the same time, all patients diagnosed as acute coronary syndromes were admitted, investigated and treated without delay. All other patients diagnosed with stable ischaemic heart disease or those with possible ischaemic disease were commenced on anti-anginal therapy, including aspirin, or had medical therapy optimized. Of the patients with possible ischaemic heart disease, 62% were already on aspirin at the time of their clinic attendance. There was also a significant reduction in the cardiology out-patient referrals (116) compared to the default management (323). Moreover, the rapid-access chest pain clinic patients who were referred onwards to cardiology out-patients, were those who had an established or highly suspected diagnosis of ischaemic heartdisease necessitating further investigations or follow-up.
There are three main areas of concern regarding chest pain clinics. Firstly, do they increase the workload of cardiology services by referring more patients for invasive investigations? In this study, 49 of the 51 patients with acute coronary syndromes had in-patient angiography and 39 patients were referred for revascularization. This in itself would highlight the significant nature of their disease. Moreover, positive cardiac troponins and strongly positive stress tests are acceptable criteria for invasive investigations.15 These patients, when managed by an alternate approach, would have been admitted for similar investigations following a significant delay.
Secondly, how reliable and safe is the triage protocol used by rapid-access chest pain clinics? Of the 565 patients (99.6% of those eligible) who have completed their 3-month follow-up, none of the patients initially diagnosed as non-ischaemic chest pain have had any major cardiac events. There have been two cardiac deaths in the acute coronary syndromes group, both these patients had been admitted from the rapid-access chest pain clinic and their investigations had already revealed them to be at high-risk. Two sudden deaths occurred in patients in the stable or possible ischaemic heart disease groups. Both were elderly (ages 82 and 76 years) and their initial investigations did not indicate a need for immediate further investigation. Both deaths occurred approximately one month after the rapid access chest pain clinic visit. One non-Q-wave myocardial infarction occurred in a patient diagnosed with stable ischaemic heart disease, and two further myocardial infarctions occurred in patients with possible ischaemic heart disease, 5 and 6 weeks, respectively, after their initial rapid access chest pain clinic visit, and who were awaiting myocardial perfusion imaging because of inconclusive exercise stress tests. Both these patients had been provisionally commenced on aspirin and sub-lingual nitrate. As a result of these two patients, we have endeavoured to speed up subsequent evaluation in such patients, with some success. Therefore the overall serious cardiac adverse event rate, at 3 months, in those patients not classified as acute coronary syndromes, is less than 1% of the study population. There were 11 readmissions for angina from the 565 patients available for follow-up: 6 /11 were in patients with acute coronary syndromes, four in stable ischaemic heart disease and one in a patient with possible ischaemic heart disease. None of the patients diagnosed as non-ischaemic chest pain were readmitted.
The third major concern about rapid access chest pain clinics is their cost-effectiveness. We performed a simple cost-effectiveness analysis, which estimated a saving of £58 per patient seen (Table 3). Rapid-access chest pain clinic expenditure was calculated for staff salaries and investigations (cholesterol, troponins, myoglobin, CK, CKMB, stress testing and/or perfusion imaging). Savings were estimated, based on the default management, from the potential reduction in hospital admissions and out-patient referrals. General cardiology in-patient bed occupancy in our unit costs £238 per day. This does not cover in-patient investigations. The total number of estimated saved admissions was 209. This figure has two components, firstly, the number of directly saved admissions (i.e. default admissions minus actual admissions 103 patients), and secondly patients with a default management of Accident & Emergency referral. An independent audit of chest pain attendances at the Royal Victoria Hospital's Accident & Emergency Dept estimated that 72–88% of chest pain referrals to Accident & Emergency were admitted. This is in keeping with findings in this study that 73% of rapid access chest pain clinic referrals (default management) from Accident & Emergency would otherwise have been admitted. Using this as a guide, we estimated a further saving of 106 patients (i.e. 72% of default Accident & Emergency referrals). The reduction in out-patient referrals was also considered on the same basis, and that the current charge for an out-patient cardiology appointment is £100 (no charge for a rapid-access chest pain clinic appointment yet applies). Thus the total charge for the reduction in out-patient referrals was added to the saved admissions. All exercise stress testing was performed and reported by the clinic doctor. This permitted stress testing to be conveniently fitted in around the time of the patient's attendance, in addition to and not in place of, the spaces available for routine hospital exercise stress tests. Costs therefore were calculated for exercise stress testing consumables only. All pharmacological stress tests and perfusion imaging (120 tests) performed were included in rapid-access chest pain clinic expenditure. A recent business case looking at our clinic funding gave an estimate of the cost for blood investigations (as listed above) at £16 per patient. However, we have not included the cost of in-patient investigations (invasive and non-invasive) in those admitted, nor did we include the costs of any potential investigations for those patients who would have been admitted according to the default management.
We could not find any cost-effectiveness data in the literature from rapid-access chest pain clinics in UK. Chest pain observation units attached to emergency departments, where patients who are at low risk of myocardial infarction undergo a short period of rigorous monitoring and serial ECG and enzyme evaluation, are popular in the US.16 Data from these centres comparing costs of a chest pain observation unit with routine care of patients suggest a significant reduction in costs per patient seen.16 A recent study of a chest pain observation unit in the UK supports these findings, although with more moderate savings.17
Previous studies have shown that many patients with new-onset angina are managed by nitrate therapy alone in the community, and despite national guidelines, few are referred for specialist opinion.3,18 At present, there are three main management strategies for general practitioners to deal with such patients: referral to a cardiac out-patient clinic, referral for open access exercise stress testing, or referral to an Accident & Emergency department for evaluation and possible hospitalization. The current waiting list for cardiac out-patients appointments in the UK is sizeable, and our hospital is no exception, with waiting times for a routine cardiology out-patient appointment of 8–18 weeks. This can result in diagnostic and treatment delay in potentially high-risk patients. Open-access exercise stress testing is a useful method for confirming suspected ischaemic heart disease in patients in the community.19 Nevertheless, experience shows that 80% of General Practitioners do not feel sufficiently confident to interpret the results of the exercise stress test, and almost half of the patients with positive exercise stress tests are subsequently referred for a cardiac opinion.18,19 Moreover exercise stress testing has limitations: it could be falsely negative in approximately 30% of patients with single-vessel disease, and thus may be inappropriately reassuring.20 Referral to Accident & Emergency results in a large number of these patients being hospitalized. Patients with acute central chest pain account for 20–30% of emergency medical admissions, yet fewer than half will have a final diagnosis of myocardial infarction or unstable angina.21 The majority of the low-risk patients are admitted for fear of missing acute cardiac ischaemia. This represents an inappropriate use of resources. On the other hand, a small proportion of patients who are released from the Accident & Emergency departments are subsequently found to have myocardial infarction (approximately 7%).22 This accounts for one of the highest losses in malpractice.22 Therefore identification of high-risk patients requiring hospital admission and safe discharge of low-risk patients clearly remains a problem.
To help in risk stratification, we assessed the importance of a number of biochemical markers of myocardial injury. The majority of patients seen (85%) had the onset of their pain >12 h from the time of their clinic attendance, and only 3% had an onset of chest pain <4 h. Thus the cardiac troponins were the most useful of the markers evaluated. Nevertheless, only 26 patients (4%) had positive cardiac troponins at their initial assessment, though 10 of these patients had a normal resting ECG. Less useful, and reflecting the less acute nature of the chest pain patients seen in the clinic as compared to the A&E setting, was myoglobin. In only two patients, both with pain <6 h, was the myoglobin level raised with initial negative troponins but with subsequent rise in troponin levels. Both these patients had abnormal ECGs. Myoglobin appears to be most useful where the clinical suspicion of early myocardial injury is high. Given the availability of troponin assessment, CK and CK-MB activity added little to the overall risk stratification. While troponin measurement in all patients, and in particular the use of point-of-care testing, added not insignificantly to the cost of the clinic, nevertheless this latter facility was of particular usefulness providing additional reassurance prior to stress testing and ensuring a rapid patient turn-around.
In addition to initiating appropriate treatment and investigating these patients, rapid-access chest pain clinics offer several other advantages over present conventional management strategies. The aim of rapid-access chest pain clinics is to see referrals quickly, thus avoiding delay and patient anxiety. Seventy percent of patients in our study were seen within 24 h of receipt of referral. The risk-factor profile of an individual is better defined, which is rarely possible in a busy Accident & Emergency department. All patients in our study had detailed risk profile assessment: 10 (1.4%) patients with new-onset diabetes were detected, 120 (17%) patients had random cholesterol levels high enough to warrant rechecking by their General Practitioner, and in 51 (7%) lipid-lowering therapy was recommended. The diagnosis of possible ischaemic heart disease was made only in 144 (20%) of the 709 patients, the majority of whom underwent further investigation (usually in the form of myocardial perfusion imaging) in an attempt to further clarify their risk profile. Finally, referring doctors are given a definitive diagnosis with less equivocation in the majority of cases.
In conclusion, a chest pain clinic run by trained staff, offers the rapid assessment of patients with suspected cardiac ischaemia, allowing for early investigation and treatment, while reducing unnecessary hospitalization of patients with non-cardiac chest pain or stable angina. Although the potential savings from a reduction in hospital admissions may be offset by a possible increase in invasive investigations in high-risk patients, the early detection of such patients should reduce morbidity and probably mortality, with an overall gain in quality-life years.
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Acknowledgments |
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We thank MSD for a grant towards running the rapid access chest pain clinic and Mr W. McNair and Mrs H. Long for technical assistance and data collection.
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Notes |
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Address correspondence to Professor A.A.J. Adgey, Regional Medical Cardiology Centre, Royal Victoria Hospital, Belfast BT126BA. e-mail: jennifer.adgey{at}royalhospitals.n\|[hyphen]\|i.nhs.uk
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