Rapid access chest pain clinic referral form BLANK

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Rapid Access Chest Pain Clinic Referral Form
Please complete form and fax with ECG to 020 8401 3022
Direct line to RACPC co-ordinator: 020 8401 3043
Referrals without an ECG and incomplete forms will be returned
Refer these patients to
A&E
Referral criteria for
Hospital and
Community Rapid
Access Clinics
Manage in Primary
Care


Rapidly accelerating or unstable angina
Suspected acute or recent MI


Males >30 years old or females >40 years old
Recent-onset (within 6 weeks) of exertional chest pain suggesting new
diagnosis of ischaemic heart disease (IHD)
New/worsening symptoms in a known IHD patient who is not under follow-up
by a cardiologist

If you are concerned about a patient that does NOT fit the above criteria (e.g. anginaequivalent breathlessness) , please– use GP advice service:
Email: [email protected];
Web: Cardiology Advice Service
(web link to medical management of angina guidelines):
Patients with existing angina previously assessed by a cardiologist whose
symptoms are well-controlled by anti-anginal medication
Initial primary care management
Lifestyle / risk factor advice – smoking cessation, healthy eating, physical exercise
Start aspirin 75mg od and sl GTN
Consider regular anti-anginal e.g. bisoprolol 2.5mg od if limiting angina requiring frequent sl GTN use
Patient details
GP details
First name:
GP name:
Last name:
Practice:
Address:
DOB:
Referral details
Phone:
NHS number:
Date of referral:
Ethnicity
Interpreter:
Medications (please complete)
History of chest pain / discomfort (please complete)
Score (mark then calculate total)
Front of the chest/epigastric/neck/shoulders/jaw/arms
1
Right-side/sub-mammary/very localised
0
Type of pain
Constricting/Heavy/Ache/Burning
Stabbing/Sharp
1
0
Precipitating factor
Always on exertion, relieved by rest
Both at rest and exertion
Nothing in particular/wholly unpredictable
Breathing in / out
1
0
0
0
Duration of episodes
2-15 minutes
Seconds-couple of minutes
More than 15 minutes to hours
1
0
0
Position on chest
Total
If score is 3-4
If score is 2
If score is 0-1
this may represent angina – Refer to rapid access chest pain clinic
see risk factor score below - if risk factors score ≥1, REFER – otherwise, treat risk factors using primary
prevention risk calculator http://www.qrisk.org
it is unlikely to be angina – consider alternative cause for chest pain, do not refer; if risk factors score ≥1,
treat risk factors http://www.qrisk.org
Risk factors (desirable)
Diabetes mellitus
Cholesterol > 6.5mmol/l
History of Smoking
Family history of a first-degree relative with premature coronary disease
Hypertension
Score
1
1
1
1
1
Known IHD?
Yes
Clinical examination and investigation (attach or write-in results, please) *essential
Pulse:*
Blood Pressure:*
Heart Murmur:*
Yes / No
Hb:*
Creat:*
TFT:
12-lead ECG report:*
CXR requested*
Where would your patient prefer to be seen? (please tick)
Croydon University Hospital
Shirley Clinic, 135 Shirley Road, CR0 7LR
Parkway Health Centre, Parkway, New Addington, CR0 0JA
Purley War Memorial
Other hospital (please specify)
No preference, Earliest available appointment
No
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