Article Text

PDF

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
  1. C Sheppard,
  2. J Edmund,
  3. K Frawley,
  4. G Dubey,
  5. J Baron,
  6. S Burn,
  7. T Azeem,
  8. M Bhandari,
  9. K Chitkara,
  10. A Tukan,
  11. A McCance,
  12. D J Kelly
  1. Royal Derby Hospital

    Abstract

    Introduction In March 2010 NICE clinical guideline number 95 described a new protocol-driven pathway for the investigation of chest pain of recent onset. This emphasised the importance of establishing pre-test probability of coronary artery disease and encouraged the use of non-invasive coronary and myocardial perfusion imaging. We sought to determine the impact of these changes on resource utilisation in particular coronary angiography and need for out-patient review.

    Methods Clinical disposition for patients attending the nurse-led Rapid access chest pain clinic (RACPC) at Royal Derby hospital between January and August 2011 was analysed using a dedicated database. During this period an established exercise tolerance test-driven protocol was in place. The proposed NICE RACPC protocol was applied retrospectively to this cohort to produce a projected model of outcomes. The new RACPC protocol was implemented in July 2012 and disposition was recorded prospectively for 'real-world' patients attending between July and November 2012. Proportions were compared with Pearson's χ2 test and p value of <0.05 was taken to be significant.

    Results Results are summarised in figure 1. A total of 916 patients were analysed: 360 patients attended RACPC between July and November 2012 and 556 during 2011. Of these 517 (56.4%) were male. 364 (39.7%) were deemed inappropriate referrals by NICE criteria and were discharged to the GP. Typical angina was diagnosed in 191 (20.8%) and non-angina symptoms in 333 (36.4%). 562 (61.4%) underwent a treadmill exercise tolerance test, of which 136 (14.9%) were reported as positive for ischaemia.

    Figure 1

    Patient dispositions following RACPC attendance (A) during 2011 (n=556) under the existing RACPC protocol (B) using retrospective modelling of the proposed new NICE-recommended protocol applied to the same cohort of patients, (C) July to November 2012 (n=360) using the revised NICE protocol. Legend: GP- discharged to general practice; CTCA- CT coronary angiogram; MPS- stress myocardial perfusion scan; Angio- Coronary angiography; OPA- referred for cardiology review without further tests; Admit- Direct admission to hospital from RACPC.

    Implementation of the new protocol-driven RACPC pathway during 2012 resulted in a significant reduction in cardiology clinic follow-up compared with 2011 (2% vs 23%, p<0.0001). Rates of discharge to the GP upon initial consultation were higher (67.5% vs 60%, p=0.02) with fewer direct admissions from RACPC (3% vs 6%, p=0.008), whereas the rate of coronary angiography (10.3% vs 8%, p=0.57) was similar. The rate of myocardial perfusion scanning remained similar (9.2% vs 6%, p=0.13) while uptake of CT coronary angiography currently was lower than predicted by NICE at 2.5%. Observed rates of angiography and MPS during 2012 were similar to those predicted by the NICE retrospective model.

    Conclusions In this ‘real-world' study, implementation of the 2010 NICE guidance on the initial evaluation of chest pain of recent onset with a protocol-driven RACPC pathway resulted in a greater proportion of initial discharge to primary care with less frequent outpatient review and similar rates of referral for coronary angiography. Utilisation of non-invasive coronary imaging in the initial assessment of chest pain is likely to expand and longitudinal outcome studies are required to confirm the safety of revised RACPC protocols.

    Statistics from Altmetric.com

    Request permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.