Rapid access chest pain clinic (RACPC)

Transcription

1 Rapid access chest pain clinic (RACPC)

2 Context Coronary heart disease (CHD) remains the common cause of death and premture death in the UK with 15% of men and 7% of women dying from the disease. UK death rate still higher than most Western European countries In the UK up to 1% of GP visits due to chest pain 5% of ED visits attributed to chest pain NICE CG

3 RACPC at the L&D Running since 2001, initially medically led Nurse-led since 2008 with medical cover One part-time nurse-prescriber until 2011 One full-time nurse-prescriber Recruiting another two in 2018, one aiming at providing an inpatient-primary care bridge 1500 new patients seen annually, Waiting time up from 2 weeks to 8 weeks in 12 months

4 RACPC Pathway Traditionally Patient presents with chest pain Attends either GP surgery or ED Referred to RACPC Now Patient still referred via primary care ED/ inpatients commonly referred internally to RACPC, not back to GP

5 Anginal Chest pain Anginal chest pain is defined as: Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms. Precipitated by physical exertion Relieved by rest or GTN within about 5 mins NICE 2010 amended 2016

6 Typicality of chest pain Presence of the three features is defined as typical angina Presence of two suggests atypical angina Presence of one or none of these features suggests non anginal chest pain

7 Unlikely angina Continuous or very prolonged and/ or Unrelated to activity and/ or Brought on by breathing in and/or Associated with symptoms such as dizzyness, palpitations, tingling or dysphagia Consider causes of chest pain other than angina (such as gastrointestinal or musculoskeletal) NICE 2010

8 Other broadly cardiac causes of chest pain Hypertrophic cardiomyopathy Pericarditis Myocarditis Cardiac sarcoidosis Cardiac amyloidosis Aortic dissection Mitral or aortic stenosis Myxoma/ Cardiac sarcoma (rare cause)

9 Non cardiac chest pain Costochondritis Musculoskeletal injury Chest infection Arthritis Pleurisy Fibromyalgia Pulmonary embolus Oesophagitis/ gastritis/ hiatus hernia/ ulcer Cholecystitis Mastitis shingles

10 Physical assesment ECG 12 lead Chest x-ray BP both arms Heart sounds, auscultation, carotids Palpating for chest wall/ shoulder, arm and epigastric / abdominal tenderness Pulsatile abdomen? Peripheral circulation/ radiofemoral delay Raised JVP Peripheral oedema

11 Risk factors/ Lifestyle (reflected in Q-risk score) Diabetes mellitus, duration Smoking Raised lipids Cerebrovascular or peripheral vascular disease Hypertension Family history (first degree relative) CKD Rheumatoid arthritis Atrial Fibrillation Alcohol Previous cardiac events Caffeine intake Weight training/ physical occupation Obesity/ metabolic syndrome

12 Diagnostics 12 lead ECG 64 slice CT coronary angiogram +calcium scoring Myoview Perfusion scan (MIBI) Cardiac Stress perfusion MRI (tertiary centre) Exercise ECG Coronary angiogram Echocardiogram/ Dobutamine stress echo/ Bubble/TOE 24/48/72 hour tape Cardiac loop/ memo/ reveal device

13 Subsequent management Revascularisation (PCI or CABG)/ Valve surgery Medical management Followup in specialist clinics (cardiomyopathy, dysrhythmia) Serial imaging, (eg Echo, MRI) Referral within the trust to other specialities, ie respiratory, endocrine Referral externally-ie tertiary centres/ community nurses

14 Medically managing the patient while waiting for appointment Optimise anti-anginals/ BP /Heartrate. If cardiac chest pain, will make a difference. Beta-blocker or Ivabradine (if bb contrindicated) Alternatively, Calcium channel blocker if not already on for HTN, (Diltiazem/ verapamil for rate control, if no heart faliure.) Start Statin and Aspirin,plus PPI if cardiac cause unclear Nitrates. Suggest GTN prophylactically

15 Higher Risk Patients Resting ischaemic ECG changes without chest pain, especially in Diabetics High risk combination -DIABETES, ETHNICITY, HIGH LIPIDS, SUBOPTIMAL BP CONTROL, SMOKING, PVD Breathlessness in Diabetics is anginal equivalent

16 Challenges The elderly/ frail/ prior revascularisation. What are we aiming to achieve? The young Iron deficiency anaemia Hypertensive heart disease Unstable angina vs non cardiac chest pain

17 My challenges Capacity Vetting referrals Casting the net widely re diagnostics CTCA- a screening service? Could more be done in the surgery? Onward referral for non- cardiac issues

18 Scenario 1 27 year-old man, policeman, desk job Medical history of hiatus hernia Sharp central chest pain radiating to L arm and scapula while on cross-trainer, eased after a few seconds, now avoids exertion Also infrequent pressure-like sensation in chest Slight SOB on exertion

19 Scenario 1 (cont) Raised cholesterol -6, LDL 4.8 Grandfather had angina Esomeprazole gave him chest pain Exercise test suggestive of subtle anterolateral changes, SOB, no chest pain Subsequent normal Dobutamine stress echo

20 Scenario 2 Male, age 54, Bangaladeshi origin, Diabetic, family history IHD, HTN, mildly raised lipids-chol 5.4, non smoker Exertional Shortness of breath only for past 2-3 months. Resting mild ST depression V2-3 Referred for coronary angiogram-significant single vessel disease- MIDCAB to LAD

21 Scenario 3 48 year-old female, pre-obesity, Hypertensive, high lipids- cholesterol 6.5 Recent ex-smoker Getting sharp L sided chest pain, sometimes exertional, sometimes after meals, noticing more SOB as well

22 Scenario 3 (cont) Inconclusive ETT Referred for CTCA-70% ostial Circumflex disease, minor atheroma elsewhere Dobutamine stress echo- no ischaemia Aggressive preventative measures put in place