Figure 1
Fig.1 Study Diagnoses of Chest Pain (consistent with NICE CG95 definitions)
Typical Stable Angina= exertional chest pain, relieved by rest
Possible Angina/Atypical angina= atypical chest pain with at least 1 CVS risk factor
Non Cardiac Chest pain= Either atypical chest pain with no CVS risk factor or a clear non-cardiac cause (this group has a
low Qrisk2 score consistent with low 10 year risk of CVS event)
Figure 2
Fig.2 – Results of Study 1: Preliminary study to assess the quality of RACPC referrals at KGH
Number of patients seen at KGH RACPC = 167 (unselected, consecutive pts. referred to RACPC, no patient excluded)
GP assessment of Chest Pain pts.
Non-Cardiac Chest Pain 5%
Possible Atypical Angina or Typical Angina 95%
Cardiologist assessment of Chest Pain
Non-Cardiac Chest Pain 55%
Possible Atypical Angina or Typical angina 45%
GP: specialist Correlation statistic
1:11
Average wait after referral received = 11.0 days
Figure 3: Old BHRUT Rapid Access Chest Pain Clinic Referral Form
Figure 4: New BHRUT Rapid Access Chest Pain Clinic Referral Form
BHRUT Rapid Access Chest Pain Clinic Referral Form - Fax to 020 89708191
Referral Criteria: New or recent onset of EXERTIONAL chest pain suggestive of STABLE
ANGINA. Male ≥30 or Female ≥40yrs. No known IHD or prior investigation within 5yrs
Date
Patient details
GP details
Name
Sex
DOB
NHS Number
Hosp. Number
Address
GP name
Practice name
Practice address
Postcode
Telephone
Fax
Telephone
Interpreter needed YES/NO
if yes, language
History of chest pain/discomfort
______________________________________________________
Relevant PMHx._________________________________________
Prior Ix. or Rx?__________________________________________
Chest Pain Score
Precipitating factor
Always on exertion, relieved by rest
Emotional stress/exposure to cold/after meal
Nothing in particular/unpredictable
Breathing in/out
3
1
0
-1
Position on chest
Front of chest/neck/shoulders/jaw/arms/epigastric
Right-side/sub-mammary/very localised
1
0
Type of pain
Constricting/cramping/heavy/tight/burning/dull ache
Stabbing/sharp
Reproducible by manual pressure on chest wall
1
0
-1
Duration of pain
< 15 minutes
Few seconds only
> 15 minutes to hours
1
0
-1
Total Chest Pain Score
_____
If score is 3 or more Typical stable angina – REFER
If score is 2
Possible atypical angina - if ≥1 risk factors listed below, REFER
If score is ≤ 1
Unlikely to be stable angina – consider alternative cause, DO NOT REFER
Risk factors
Diabetes mellitus
Yes / No
Cholesterol > 6.47mmol/L
Yes / No
Current smoker or recent Ex-smoker
Yes / No
Family Hx. of a first-degree relative with coronary disease <60yrs
Yes / No
Hypertension
Yes / No
Past history of IHD? Yes/No If Yes, REFER TO CARDIOLOGY CLINIC IF SUSPECT CARDIAC ORIGIN
Clinical examination and investigation
Murmur Yes / No
Anaemia Yes / No
BMI
Chol
BP
eGFR
ECG Normal / AF/ LBBB / Unknown / Other_____
LV Dysfunction Yes / No / Unknown
Figure 5
Fig.5 Results of Study 2: A pilot study testing the effectiveness of chest pain symptom scoring in improving GP
discrimination of chest pain
Pilot Study Outcomes Total N=79
Novel Form
N=
_______
Conventional Form
27
_______ _____52_____
NC%
40.7%
44.4%
TA/PA%
59.2%
50%
Chi Sq analysis p value
<0.19
GP:Spec. correlation statistic
1:5
<0.16
1:11
Average wait to be seen 9.4 days
Figure 6:
Fig. 6 Results of Study 3: Review of RACPC patient diagnosi s post implementation of new referral form
Feb-Apr
Feb-Apr
2011-3
2014 actual
% change
P value
mean ±s.d
No. of referrals
353± 51
248
-29.7 %
P<0.05
% NonCardiac
38.9± 3.4
32.8
-18.6 % relative
Not significant
chest pain
Mean wait/
days
reduction
10.6±0.4
9.8
Not significant