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NICE guidelines in the Sunderland RACPC cohort study: one size does not fit all

Kerrick Hesse1, Zaw Htet2, Mickey Jachuck3

  • 1Cardiology Registrar (ST6).

The British Journal of Cardiology
|August 15, 2024
PubMed

Insights

Patients with typical angina in rapid access chest pain clinics (RACPC) face higher risks of obstructive coronary artery disease (CAD) and major adverse cardiovascular events (MACE). Invasive coronary angiography (ICA) remains effective for diagnosis and treatment when CTCA capacity is limited.

Area of Science:

  • Cardiology
  • Diagnostic Imaging
  • Public Health

Background:

  • Undifferentiated chest pain accounts for significant general practitioner (GP) and accident and emergency (A&E) attendances.
  • Rapid access chest pain clinics (RACPC) manage suspected cardiac chest pain, with NICE guidelines recommending computed tomography coronary angiography (CTCA) as a primary investigation.
  • Evaluating the effectiveness and efficiency of local RACPC services is crucial for optimizing patient care.

Purpose of the Study:

  • To assess the effectiveness and efficiency of a local RACPC in the Northeast of England.
  • To compare demographics and major adverse cardiovascular events (MACE) among patients with typical, atypical, and non-angina chest pain.
  • To analyze the outcomes of anatomical and functional imaging, including CTCA and invasive coronary angiography (ICA).

Main Methods:

  • Retrospective analysis of 401 unselected referrals to a RACPC in 2021.
  • Comparison of baseline demographics and MACE based on chest pain classification (typical, atypical, non-angina).
  • Modeling of obstructive coronary artery disease (CAD) incidence using backward stepwise binary logistic regression.

Main Results:

  • Of 373 patients with chest pain, 37.3% had typical angina, 32.8% atypical, and 30.0% non-angina.
  • Typical angina patients were older, had more cardiovascular risk factors, and a significantly higher risk of obstructive CAD (OR 6.27) and MACE (9.4%).
  • 164 patients underwent ICA, revealing obstructive CAD in 26.2%, while 39 patients had CTCA, with 25.6% requiring subsequent ICA.

Conclusions:

  • Patients presenting with typical angina exhibit a heightened risk of cardiovascular events.
  • In settings with limited CTCA capacity, invasive coronary angiography (ICA) effectively diagnoses CAD and enables timely revascularization.
  • Enhanced risk stratification and expanded non-invasive imaging are recommended to improve RACPC service delivery within cardiology networks.

Keywords:
anginacomputed tomography coronary angiographycoronary artery diseaseinvasive coronary angiographyrapid access chest pain clinic

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