How Effective Are Rapid Access Chest Pain Clinics? Prognosis of Incident Angina and Non-Cardiac Chest Pain in 8762 Consecutive Patients

Newham University Hospital, London, UK.
Heart (British Cardiac Society) (Impact Factor: 5.6). 05/2007; 93(4):458-63. DOI: 10.1136/hrt.2006.090894
Source: PubMed


To determine whether rapid access chest pain clinics are clinically effective by comparison of coronary event rates in patients diagnosed with angina with rates in patients diagnosed with non-cardiac chest pain and the general population.
Multicentre cohort study of consecutive patients with chest pain attending the rapid access chest pain clinics (RACPCs) of six hospitals in England.
8762 patients diagnosed with either non-cardiac chest pain (n = 6396) or incident angina without prior myocardial infarction (n = 2366) at first cardiological assessment, followed up for a median of 2.57 (interquartile range 1.96-4.15) years.
Primary end point--death due to coronary heart disease (International Classification of Diseases (ICD)10 I20-I25) or acute coronary syndrome (non-fatal myocardial infarction (ICD10 I21-I23), hospital admission with unstable angina (I24.0, I24.8, I24.9)). Secondary end points--all-cause mortality (ICD I20), cardiovascular death (ICD10 I00-I99), or non-fatal myocardial infarction or non-fatal stroke (I60-I69).
The cumulative probability of the primary end point in patients diagnosed with angina was 16.52% (95% confidence interval (CI) 14.88% to 18.32%) after 3 years compared with 2.73% (95% CI 2.29% to 3.25%) in patients with non-cardiac chest pain. Coronary standardised mortality ratios for men and women with angina aged <65 years were 3.52 (95% CI 1.98 to 5.07) and 4.39 (95% CI 1.14 to 7.64). Of the 599 patients who had the primary end point, 194 (32.4%) had been diagnosed with non-cardiac chest pain. These patients were younger, less likely to have typical symptoms, more likely to be south Asian and more likely to have a normal resting electrocardiogram than patients with angina who had the primary end point.
RACPCs are successful in identifying patients with incident angina who are at high coronary risk, but there is a need to reduce misdiagnosis and improve outcomes in patients diagnosed with non-cardiac chest pain who accounted for nearly one third of cardiac events during follow-up.

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    • "Despite this low incidence, the adverse consequences for a missed diagnosis of CAD where early treatment can be highly effective are substantial [2]. This recognition has led to the development of rapid access chest pain clinics whereby general practitioners may refer patients with chest pain to experienced specialists with access to further basic and advanced diagnostic testing [3]. Here, it is recommended that the 2010 National Institute for Health and Clinical Excellence (NICE) guidelines for stable chest pain be followed [2]. "
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    ABSTRACT: To evaluate diagnostic strategies in a rapid access chest pain clinic (RACPC) in the United Kingdom and to predict the economical and clinical impacts of incorporating fractional flow reserve by coronary computed tomographic angiography (FFRCT) into future pathways. A retrospective analysis of consecutive patients referred to a RACPC in the United Kingdom. All patients had an evaluation of cardiovascular risk factors and symptoms from which the pre-test likelihood (PTL) of coronary artery disease (CAD) was evaluated using the Diamond Forrester (DF) criteria. All investigative strategies and their results were recorded. For the FFRCT economic evaluation of 1000 patients, standard National Health Service Tariffs were then applied and compared with a strategy that utilised FFRCT for varying PTL categories. There were 410 patients with a median age of 57 (31-85) years. The DF criteria classified 39 (9.5%) patients as having a PTL of <10%, 76 (18.5%) 10-29% PTL, 117 (28.5%) 30-60% PTL, 114 (27.8%) 60-90% PTL and 64 (15.6%) >90% PTL. The concordance with the NICE recommended guidelines was <50% with the prevalence of obstructive CAD being <5% in patients with a PTL <90%. A model utilising FFRCT for patients with a PTL 10-90% predicted a 48% and 49% reduction in invasive angiography and percutaneous coronary intervention, a saving of £200 per patient and a reduction in relative adverse event rates of 4%. The DF algorithm overestimates the PTL of CAD supporting an extended role for coronary CTA. Strategies incorporating FFRCT may confer benefits in evaluating patients with stable chest pain. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
    Full-text · Article · Feb 2015 · International Journal of Cardiology
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    • "and tests for accurate and efficient evaluations of patients with chest pain, about 3% of these released patients suffer of silent AMI [3]. A rapid triage of patients with symptoms of chest pain is, thus, necessary to obtain a lower mortality rate by achieving an early healthcare evaluation and a suitable interventional assistance and/or medication [4], [5]. Computational models are feasible sources to support decision making during diagnoses by identifying and treating actual health problems of patients. "
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    ABSTRACT: A fuzzy medical diagnostic decision system for helping support to evaluate patients with anginal chest pain and obesity clinical condition is proposed in this paper. Such an approach is based on the Braunwald symptomatic classification, the fuzzy set theory and fuzzy logic, and a risk obesity factor determined by a simplified Fuzzy Body Mass Index (FBMI). The fuzzy Braunwald symptomatic classification intertwined with the fuzzy obesity risk factor overwhelm the current rapid access chest pain clinic approaches that do not discriminate the obesity comorbidity or takes into account the subjectiveness, uncertainty, imprecision, and vagueness concerning such a clinical health condition. The resulting fuzzy obesity-based Braunwald symptomatic chest pain assessment is an alternative to support healthcare professionals in primary health care for patients with anginal chest pain worsened by the obesity clinical condition.
    Full-text · Conference Paper · Jul 2014
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    • "A meta-analysis of data from 31 countries indicated the population weighted prevalence was 6.7% in woman and 5.7% in man [4]. Angina is a common initial presentation of coronary disease [5], and it may exert a major impact on quality of life, ability to work, and costs to society [6, 7]. "
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    ABSTRACT: Chinese herbal medicine (CHM) has been widely used as an adjunct to western medicine in treating angina in China. We carried out this systematic review to evaluate the effectiveness of CHM on top of western medicine for angina. This meta-analysis included 46 randomized control trials with 4212 patients. For trials that included stable angina patients, the CHM group had significant lower incidence of total heart events (relative risk (RR) = 0.50, 95% confidence interval (CI) 0.33-0.78), myocardial infarction (RR = 0.32, 95% CI 0.14-0.72), heart failure (RR = 0.37, 95% CI 0.15-0.91), and angina (RR = 0.46, 95% CI 0.30-0.71) than that of control group. For trials that included unstable angina patients, CHM led to significantly lower occurrence of total heart events (RR = 0.46, 95% CI 0.32-0.66), myocardial infarction (RR = 0.37, 95% CI 0.26-0.54), and angina (RR = 0.36, 95%CI 0.26-0.51). Likewise, for trials that included stable or unstable angina patients, the rates of myocardial infarction (RR = 0.34, 95% CI 0.17-0.68) and angina (RR = 0.46, 95% CI 0.30-0.70) in CHM group were significantly lower than that in control group. In conclusion, CHM is very likely to be able to improve the survival of angina patients who are already receiving western medicine.
    Full-text · Article · Dec 2013 · Evidence-based Complementary and Alternative Medicine
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