Intoduction The rapid access chest pain (RACP) service model aims to fast-track the diagnostic evaluation of suspected cardiac chest pain with the aid of exercise electrocardiography (ECG). However, approximately 25–30% of patients are either unable to exercise or have an equivocal exercise ECG and it is unclear how this might affect the long-term clinical outcome.
Aim The aim of this study was to determine the independent predictors of all-cause death in patients attending the RACP service from January 2004 to December 2006.
Methods A total of 2199 patients attended the RACP clinic during the study period. Of these, 316 patients were inappropriate referrals and were therefore excluded from the analysis. The study cohort consisted of 1883 patients who were considered eligible for ischaemia testing. The parameters analysed included age, sex, ethnicity, diabetes, hypertension, hypercholesterolaemia, smoking, previous coronary artery disease (CAD) and exercise ECG findings (diagnostic test vs inconclusive test or inability to exercise). Pretest probabilities were low in 19%, intermediate in 62% and high in 19% of the patients.
Results A total of 66 all-cause deaths were recorded during a mean follow-up period of 39.4 ± 9.9 months. Comparison of the demographic data and the management plans of the patients who died versus those who survived are shown in tables 1 and 2. Those who died were significantly older, had higher prevalences of smoking, diabetes and hypertension, reflecting higher pretest probabilities of CAD. These patients were also more likely to have a non-diagnostic exercise ECG (inconclusive test or inability to exercise) and had a higher referral rate for pharmacological stress imaging, with a median waiting time of approximately 5 months. Multivariate analysis showed that age (p = 0.001), diabetes (p = 0.006) and a non-diagnostic exercise ECG (p = 0.04) were the independent predictors of all-cause death.
Conclusion Patients leaving the RACP clinic without a diagnostic exercise ECG due to an inconclusive result or inability to exercise are at higher risk of death than those with a diagnostic exercise ECG. These patients are not adequately well served by the RACP service model based on the exercise ECG. Future models of care need to incorporate early and increased access to pharmacological stress imaging with appropriate funding and resource allocation to meet the 18 weeks target.