Integrating HEART Score and Early CT Coronary Angiography in a Chest Pain Hot Clinic-A Safe Alternative to Inpatient...

Suspected cardiac chest pain is a common cause for hospital admission. In busy acute NHS hospitals, patients with suspected cardiac chest pain, normal Troponin levels, and no evidence of acute coronary syndrome are often admitted for invasive angiography or CT coronary angiography (CTCA). This has a significant impact on the length of stay, patient flow, and bed capacity. A timely ambulatory pathway for these patients to undergo urgent outpatient CTCA would avoid admission.

The aim was to design an ambulatory pathway for rapid investigation of patients with troponin-negative chest pain, as a safe alternative to admission.

A trustwide guideline was implemented, which emphasized the use of the heart score to risk-stratify patients, and determine suitability for referral to our new service. Those scoring 4-6 were deemed appropriate for the pathway and returned within 96 h to undergo CTCA, then attend the chest pain hot clinic for review. In the original HEART pathway trial, these "moderate risk" patients were admitted. A unique feature of the pathway was the agreement for non-cardiologists to book the CTCA directly, without cardiology input. This facilitated a very short time to diagnosis from the point of discharge, when compared to similar "rapid access chest pain" pathways.

A total of 349 patients were reviewed in the hot clinic between July 4, 2024, and December 31, 2024. Of these, 222 met the referral criteria and were included in the per-protocol analysis. A CTCA was performed for 215 patients, with a minority having a valid contraindication. This alone was sufficient to exclude obstructive coronary disease in 99 of those scanned (44.1%). After completion of the investigation, 87 patients (39.2%) received a final diagnosis of angina, whilst 50 patients (22.5%) had coronary disease significant enough to proceed directly to revascularization. With regards to safety outcomes, 20 patients (9.0%) were admitted from the clinic, and there was only one case of a cardiovascular-related admission prior to the appointment (0.4%), with no associated mortality after 6 months.

Our center's experience demonstrates the feasibility and safety of managing patients presenting with moderate risk chest pain via an urgent ambulatory care pathway. There are significant benefits to this strategy relating to admission avoidance, and our low adverse event rate suggests that this is a safe model when compared to inpatient investigation.