Rapid Access Chest Pain Clinic to Cath Lab.the journey.. Jenny Deane, Clinical Nurse Specialist, RACPC, RFH

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1 Rapid Access Chest Pain Clinic to Cath Lab.the journey.. Jenny Deane, Clinical Nurse Specialist, RACPC, RFH

2 Background In the UK: Chest pain is a very common symptom between 20% to 40% of the general population will experience chest pain in their lives 1% of visits to a GP are because of chest pain Approximately 5% of visits to A&E and up to 40% of emergency hospital admissions are because of chest pain Almost 2 million people in the UK have or have had angina Around 8% of men and 3% of women aged currently have or have had angina. The figures for men and women aged are around 14% and 8% respectively. (NICE guidelines 2010: Chest pain of recent onset

3 What is stable angina? Stable angina is characterised by temporary episodes of sub-sternal chest pain/discomfort (which may be accompanied by arm or jaw pain) related to activities that increase myocardial oxygen demand & in most cases is due to gradual occlusion of the coronary arteries by atheroma. Unstable angina is characterised by worsening severity/frequency of chest pain or its occurrence at night/rest

4 What are the symptoms of stable angina? Angina is usually felt as: pressure, heaviness, tightening, constricting, squeezing, or aching across the chest, particularly behind the breastbone, but also neck, shoulders, jaw or arms. However, atypical symptoms can occur: Indigestion, heartburn, shortness of breath

5 Usual location of angina pain

6 Making a diagnosis Rapid Access Chest Pain Clinic RACPCs were established to help ensure that people who develop new symptoms that their GP thinks might be due to angina can be assessed by a specialist within two weeks of referral to prevent delay with diagnosis and treatment. Benefits: Patients symptoms and risk of CAD are assessed accurately and appropriate treatment commenced and diagnostic tests arranged Help reduce a patients risk of a major cardiac event by eliminating delay as studies show that most cardiac adverse events occur within 6 months of diagnosis Provides reassurance to patients whose symptoms are non-cardiac sounding Provides risk factor and lifestyle modification advice to all patients.

7 Who should be referred? New onset exertional chest pain Atypical chest pain with 2 or more risk factors for CAD Short lived ischaemic sounding chest pain < 20 mins duration

8 Who should not be referred? Patients with suspected cardiac chest pain at rest within past 12 hrs suspicious of ACS (including AMI, unstable angina or crescendo angina) Call an ambulance & send direct for PPCI or to A&E Non-specific chest pain in patients at low risk of CAD (i.e. without risk factors including DM; smoking, and Cholesterol) Likelihood of CAD in Men < 40 yrs & Women < 60 yrs with non-specific chest pain is LOW = < 10%

9 Who runs the service? Traditionally RACPC S were set up to be run by Clinical Nurse Specialists in Cardiology RFH model includes CNS s and a Trust Speciality Doctor joint service with a Consultant lead CNS s run the management of the service with administration support

10 What happens at the clinic? We take a detailed history of symptoms; PMH; and perform a clinical examination 12 lead ECG is recorded: may show some ischaemic changes but a normal ECG does not rule out a diagnosis of angina. changes on a resting 12-lead ECG that are consistent with CAD include: pathological Q waves; LBBB; ST-segment and T-wave abnormalities (eg flattening or inversion). However, results may not be conclusive All of the above is used to calculate the likelihood of CAD (using NICE guidelines 2010) according to age, sex, and risk factors.

11 Likelihood of CAD using NICE 2010

12 Likelihood of CAD using NICE For example guidelines 2010 (1) 47 year old man with atypical angina chest pain, no Cholesterol (>6.47 mmol/l), no diabetes and a non-smoker has a 21% likelihood of having CAD Whereas The same person s risk to 70% with all of the above risk factors

13 Likelihood of CAD using NICE For example guidelines 2010 (2) 68 year old man with typical angina chest pain, no Cholesterol (>6.47 mmol/l), no diabetes and a non-smoker has an 93% likelihood of having CAD Whereas 68 year old woman, presenting with the same symptoms and none of the above risk factors has a 56% likelihood of having CAD

14 So what do we do next? Since new NICE guidelines published in 2010 ETT no longer recommended to diagnose or exclude stable angina for people without known CAD due to it s limitations: Overall sensitivity 69%, specificity 77% Limited accuracy in patients with a low/intermediate pre-test probability of CAD or difficult to interpret ECGs

15 If significant CAD uncertain, offer functional imaging If significant CAD uncertain, offer functional imaging What alternative tests do we arrange? Estimated Estimated Estimated likelihood of CAD likelihood of CAD likelihood of CAD 10 29% 30 60% 61 90% Offer CT coronary calcium scoring If CT calcium score is: zero - investigate other causes of chest pain offer 64-slice (or above) CT coronary angiography >400 - follow pathway for 61 90% CAD Offer non-invasive functional imaging including Stress Echocardiogram and nuclear scanning such as MPI Scan If reversible myocardial ischaemia uncertain, offer invasive coronary angiography Offer invasive coronary angiography if appropriate Offer non-invasive functional imaging if invasive coronary angiography not appropriate (eg. Age, improve quality of life?, impaired renal function, pt. refuses)

16 What happens next? Discuss suspected diagnosis with patient and explain the need for further tests if required Arrange appropriate test to confirm/exclude CAD and to guide future treatment Remember: COURAGE TRIAL (2007) PCI + stenting and optimal medical therapy is no better at preventing future cardiac events than optimal therapy alone in patients with stable CAD The basis for revascularisation is for control of ischaemia

17 What happens next? (2) If angina suspected prescribe secondary prevention medication: Aspirin Betablocker or calcium channel blocker if betablocker is contraindicated to reduce heart rate thereby lowering myocardial oxygen demand, or longacting oral nitrate if HR 60bpm Statin to maintain a TC level of 4.0mmol/l and an LDL of 2.00mmol/l GTN spray for temporary relief of symptoms

18 What happens next? (3) Address risk factors and lifestyle modification Provide information booklets on condition and tests Provide a telephone contact number for further help if required

19 Case Study 1 Mr S He s the typical one! 58 year old male Presenting complaint: Left sided chest tightness on exertion for the past 6 months, eased with rest within 5-10 minutes and relieved with GTN within a few minutes no radiation, no associated symptoms, no increase in severity over the past 6 months no rest pain, no prolonged episodes of pain

20 Case Study 1 (2) PMH - nil Medication - recently commenced on aspirin and GTN spray by GP. No other meds. Allergies - Nil Social History: lives with his wife and 2 sons works as an electrician usually fit and well alcohol 30 units per week no regular exercise regime but enjoys walking Coronary risk factors: FH IHD Father died MI aged 68 Ex-smoker of 2 yrs (smoked 20/day for 35 years) Cholesterol: TC 7.1, LDL 5.2, HDL 1.1, Trig 2.0 (untreated)

21 Case Study 1 (3) Clinical examination - unremarkable Blood Pressure 145/88mmHg Pulse - regular, 78 bpm Resting ECG: Sinus Rhythm 84bpm, normal axis, no ST/T changes Chest pain assessment Typical angina Likelihood of CAD = 80%

22 Case Study 1 (4) Provisional Diagnosis: Stable angina Management Plan: Commence secondary prevention medication: Aspirin 75 mg od Bisoprol 2.5mg od Simvastatin 40mg on Placed on day case waiting list for invasive coronary angiogram with?proceed to PCI Coronary angiogram performed 4 weeks later: 90% proximal LAD stenosis. PCI and stent to proximal LAD

23 Case Study 2 Mrs B not so easy 61 year old lady Presenting complaint: 3 month history of left sided burning feeling worse on exertion but also occurs at rest. eased with rest within 5-10 minutes and also relieved by drinking water when it occurs at rest no radiation, no associated symptoms Had recently been taking Naproxen for knee pain

24 Case Study 2 (2) PMH - Hypothyroidism Medication Thyroxine 50 mcg od Allergies - Nil Social History: lives alone works as a book-keeper usually fit and well alcohol 3 units per week very active and takes regular walks daily Coronary risk factors: FH IHD Brother died MI aged 48 Non-smoker

25 Case Study 2 (3) Clinical examination - unremarkable Blood Pressure 160/90 mmhg Pulse - regular, 60 bpm Resting ECG: Sinus Rhythm 57bpm, normal axis, no ST/T changes Chest pain assessment - atypical Likelihood of CAD = 10%

26 Case Study 2 (4) Provisional Diagnosis: Possible angina Management Plan: Commence secondary prevention medication: Aspirin 75 mg od GTN spray prn GP to re-check BP in 2 weeks and commence anti-hypertensive therapy Booked for MPI Scan Results: Moderate inducible ischaemia in the anterior wall and apex Placed on day case waiting list for invasive coronary angiogram with?proceed to PCI Coronary angiogram performed 4 weeks later: 70% mid LAD stenosis. PCI and stent to mid LAD

27 Case Study 3 Mr M the unpredictable one! 45 year old male Presenting complaint: central dull ache provoked by emotional stress/anxiety, and occasionally on exertion for the past 2 months relieving factor none no radiation but associated breathlessness

28 Case Study 3 (2) PMH - nil Medication nil Allergies - Nil Social History: Single Own business very stressful job usually fit and well alcohol units per week Coronary risk factors: FH IHD Father MI aged 47 Ex-smoker of 8 months (smoked 20/day for 25 years) Cholesterol: TC 6.1, LDL 3.6, HDL 1.0, Trig 3.3 (untreated)

29 Case Study 3 (3) Clinical examination - unremarkable Blood Pressure 128/78 mmhg Pulse - regular, 62 bpm Resting ECG: Sinus Rhythm 64bpm, normal axis, no ST/T changes Chest pain assessment - atypical Likelihood of CAD = 21%

30 Case Study 3 (4) Provisional Diagnosis: atypical chest pain for further investigation Management Plan: Commence secondary prevention medication: Aspirin 75 mg od GTN spray prn Booked for CT Coronary angiogram Results: Significant 2 vessel disease: 90% proximal LAD stenosis and >70% proximal first and second diagonal branch Pt and GP informed over telephone Invasive coronary angiogram with?proceed to PCI booked as an urgent case GP to prescribe a betablocker or alternative anti-anginal agent and a statin Coronary angiogram performed on an urgent basis: 95-99% proximal LAD and 95-99% Proximal first diagonal PCI and stent to both vessels

31 Conclusion Angina has a significant impact on quality of life Assessment, diagnosis and treatment should be prompt to avoid an acute cardiac event RACP 2 week wait clinics achieve this goal Treatment, whether it be invasive PCI or medical treatment alone is focused at improving symptoms and thereby improving a person s quality of life

32 Thank you Any Questions?

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