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: mhn-tr.gpcardiologyadviceservice@nhs.net; 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