Nurse-led rapid-access chest pain clinics: effective, safe and here to stay

Richard Elis Knowles Jones; Katherine Groom; Carmen Zerafa; Paraic Cliffe; Pat Phen; Rajesh Aggarwal

doi:10.7861/clinmedicine.17-3-s1

Aims

To analyse test utilisation and revascularisation rates in a large, nurse-led, rapid-access chest pain (RACP) clinic. In addition, to assess for subsequent acute coronary syndrome (ACS) presentations in patients referred with suspected stable coronary artery disease (SCAD).

Methods

Retrospective analysis of the 4,661 patients seen at a nurse-led RACP clinic between November 2011 and October 2015.

Results

2,477 non-invasive investigations were performed as the initial test to assess for SCAD. These resulted in 93 (4%) revascularisation procedures. In contrast, 686 invasive coronary angiograms were performed as the initial investigation. These resulted in 261 (38%) patients being revascularised.

59 (1.3%) patients were admitted with an ACS requiring invasive management up to 365 days following their RACP appointment. Nine (0.2%) patients had been discharged without any SCAD work up, 30 (0.6%) were awaiting their index investigation, eight (0.2%) presented with an ACS after a negative non-invasive test, and 12 (0.3%) were awaiting revascularisation. SCAD was diagnosed in 933 (20%) of our population.

Conclusions

Invasive coronary angiography remains a common initial investigation in patients being worked up for SCAD. In support of this strategy, a high proportion of these patients subsequently undergo revascularisation. Non-invasive testing is reserved for patients with a lower pre-test probability of SCAD and, as such, considerably fewer patients in these groups are revascularised. Reassuringly, patients with suspected SCAD have a low incidence of ACS up to 1 year following diagnosis.

In conclusion, cardiac specialist nurses are skilled at detecting patients with SCAD and can deliver a safe and effective service. Readdressing the use of non-invasive testing in lower-risk groups may be appropriate, as only a small proportion of these patients had obstructive coronary artery disease in our study.