Rapid Access Chest Pain Clinics: characteristics and outcomes of patients from six centres

Abstract

Background Despite the widespread proliferation of rapid access chest pain clinics (RACPCs), there remain outstanding questions about their effectiveness. The aim of my thesis is to determine: Aim 1) the variation in the structure of RACPCs in England Aim 2) the prognosis in patients with suspected angina attending RACPCs Aim 3) the incremental prognostic value of the exercise electrocardiogram Aim 4) inequity in utilisation of and referral for coronary investigation from RACPCs and its effect on coronary outcomes Aim 5) whether the RACPC acts in addition to, or as a substitute, for outpatient cardiology clinics

Method I have analysed data on 11,082 consecutive patients from six RACPCs in England with different inclusion criterion for the specified aims and followed them up for 2.57 years for mortality and morbidity using central registries. Parallel data from outpatient cardiology clinic and RACPC were collected in a single centre for aim 5.

Results The six study centres are representative of the RACPCs established in England. Endpoints of death due to coronary heart disease (CHD) and nonfatal acute coronary syndrome were more frequent in patients diagnosed with angina but extended into those diagnosed with noncardiac chest pain who accounted for a third of the total events. The incremental prognostic value of resting and exercise electrocardiograms over and above clinical assessment was small. There was evidence of inequity in utilisation of RACPC by age and deprivation and in referral of patients for coronary angiogram by age, gender, ethnicity and deprivation, associated with adverse coronary outcomes. Single centre data showed that RACPCs have largely substituted for traditional outpatient cardiology clinics in the assessment of patients with new onset chest pain.

Conclusion The high event rates and inequity identified among unselected patients presenting to RACPC reflects ‘real world’ medicine and highlights the need for improved service provision, diagnosis and treatment to improve prognosis.