Q J Med 2001; 94: 717-718
© 2001 Association of Physicians
Commentary |
Chest pain assessment services: the next steps
From the Cardiovascular Medicine Group, Faculty of Medicine, Imperial College School of Science Technology and Medicine, Charing Cross Hospital, London W6 8RF
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Introduction |
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Improved care for patients presenting with chest pain remains high on the medical agenda. This is reflected not only in the National Service Framework (NSF),1 but also in the number and variety of publications in this area. The two articles in this issue illustrate that the questions are no longer about whether there should be specialized services for chest pain, but how best to organize such services, and the need to subject them to economic analysis. Just a year ago the question was posed: ‘Chest pain—please admit’: is there an alternative?2 The accepted answer now must be a conclusive ‘yes’. The challenge that remains is to refine the alternatives. This of itself represents a great (if as yet incomplete) victory for the protagonists of chest pain clinics and for the NSF.
Patients with suspected ischaemic chest pain present across a spectrum of illness, from acute, haemodynamically unstable patients with evolving myocardial infarcts to ambulant patients with recent-onset exertional angina. The characteristics and design of services, together with the placing in context of published reports, require an appreciation of where along this spectrum a service lies. At one end are Emergency Departments and Coronary Care Units (CCU) and their related new services, often called Chest Pain Assessment Units (CPAUs). These receive a high proportion of acute coronary syndromes and are an alternative to the standard Emergency Department facilities. Monitored beds are required, with patients staying potentially for some hours, and high subsequent admission rates. At the other end of the spectrum are Rapid Access Chest Pain Clinics (RACPCs), specifically excluding suspected acute coronary syndromes in their referral criteria, for patients to receive prompt assessment focussed around exercise stress testing. Although in practice these distinctions become blurred, and many seen in CPAUs have exertional angina, while RACPCs report a proportion, rarely below 5%, of acute coronary syndromes amongst their referrals,1,3 the division remains important. Referral criteria may give a clue to the position of services in this scheme. More often a better guide is the reported proportion with acute coronary syndromes and subsequent admission rates. Examples where the position along this spectrum has implications, are in deciding the role of cardiac injury markers, and assessing whether the likely benefits of the service are in saved out-patient appointments or saved admissions. For those establishing such services, this positioning will direct the facilities needed and their relationship with other primary and particularly secondary care services in the locality.
‘Less acute’ services should not be equated with low risk, and new-onset exertional angina is not stable angina. So while patients with new-onset exertional angina may not be in imminent danger over the ensuing hours, their morbidity and mortality over the next weeks and months are substantial, and timely investigation and treatment are still required.4 If services that follow initial assessment are delayed, whether this is further non-invasive or invasive investigation, prevention and rehabilitation programmes, or revascularization, the benefits of a prompt initial assessment will be diluted if not drowned. Dougan et al. have identified this from their comprehensive analysis of follow-up data from their RACPC, and instituted efforts to speed up second-stage investigations.5
Can there now be any doubt as to the value of troponins in managing acute chest pain? Alp et al. are to be congratulated in performing a pragmatic randomized controlled trial of the use of troponin-I in a secondary care CCU reflecting ‘real world’ circumstances familiar to all district cardiologists and general physicians.6 This work therefore adds to the substantial body of data from major centres around the world.7 They demonstrate increased efficiency in the management of patients with suspected acute coronary syndromes using bedside troponin-I. Their findings can and should be transferred to routine UK practice. Wisely, they remind us that troponin-I is not an alternative to clinical judgement, but an adjunct to it. Of note, Alp et al. used a troponin-I assay 6 h after pain onset. This adds to other reports, some using a 6 and some a 12 h time interval,7,8 and it seems that 6 h, which therefore allows even earlier discharge, is on balance acceptable.
Near-patient testing is ideally suited to a RACPC, and extending the role of troponins to RACPCs is an important step that has not been addressed previously. The nature of patients seen, as discussed earlier, means that the proportion with positive troponins is likely to be low, and explains the figure of 4% in the report by Dougan et al. from the Belfast RACPC.5 Nevertheless, the identification of this 4% is an essential role of RACPCs, and the authors note that these patients could not have been identified simply by focussing on those with an abnormal ECG. Equally valuable, a negative troponin allowed exercise testing in patients whose full assessment, and thus in many cases early reassurance, would otherwise have been delayed. However, the 96% proportion with negative troponins would suggest that some selectivity in testing might be possible.
The analysis of cost-effectiveness of chest pain services is difficult but necessary. Dougan et al. note that this has not been reported for a RACPC, and have calculated a saving of £58 per patient assessed.5 This is based on a comparison with the ‘default management’ recorded, a method also used by Newby et al. in their evaluation of a chest pain clinic.9 However, in the past the commonest default management of angina was management within primary care10 which imposes little cost on secondary care in the short term. But it is a move away from such management that represents an advance in the care of patients with suspected coronary heart disease. One would therefore not wish to judge chest pain assessment services primarily on economic grounds, although demonstrating cost savings provides further ammunition to advance their introduction. Much of the cost saving represents reduced admissions. Realistically, as Alp et al. point out, early discharge does not actually lead to empty beds in our overfilled hospitals. However, improved management of chest pain allows more efficient bed use, particularly on hard-pressed CCUs, which is to be welcomed.
Similarly, one should not be concerned that RACPCs and CPAUs increase the number of patients undergoing invasive investigations. If one assumes that subsequent revascularization decisions are based on accepted guidelines, the reported high rates of revascularization that result3,5 imply that we are identifying a large previously unmet need rather than opening the floodgates for profligate cardiologists.
In conclusion, we have moved beyond the question of whether to introduce specialized services for the assessment of suspected ischaemic chest pain. The questions service planners must now ask are: do they wish to establish services focussed on new exertional angina based around RACPCs, or services for suspected acute coronary syndromes such as traditional CCUs and CPAUs? This is not a simple choice, with combinations and hybrids all possible. For those studying such services we must now ask how best to configure these services, how best to use available staff and select investigations, and how to run them most cost-effectively. The two papers in this issue of the QJM help us to answer these questions.
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Notes |
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Address correspondence to Dr K.F. Fox, Cardiovascular Medicine Group, Faculty of Medicine, Imperial College School of Science Technology and Medicine, Charing Cross Hospital, London W6 8RF. e-mail: k.fox{at}ic.ac.uk
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References |
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TopIntroductionReferences |
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1. Department of Health. The National Service Framework for Coronary Heart Disease. London, DoH, 2000.
2.
Capewell S, McMurray J. ‘Chest pain—please admit’: is there an alternative? BMJ2000; 320:951–2.
3. Sutcliffe SJ, Fox KF, Wood DA. How to set up and run a Rapid Access Chest Pain Clinic. Br J Cardiol2000; 7:692–702.
4.
Gandhi MM, Lampe F, Wood DA. Incidence, clinical characteristics and short-term prognosis of angina pectoris. Heart1995; 73:193–8.
5. Dougan JP, Mathew TP, Riddell JW, Spence MS, McGlinchey PG, Nesbitt GS, Smye M, Menown IB, Adgey AAJ. Suspected angina pectoris: a rapid-access chest pain clinic. Q J Med2001; 94:000–000.
6. Alp NJ, Bell JA, Shahi M. A rapid troponin-I-based protocol for assessing acute chest pain. Q J Med2001; 94:000–000.
7.
Hillis GS, Fox KAA. Cardiac troponins in chest pain. Br Med J1999; 319:1451–2.
8.
Mathew TP, Menown IB, Smith B, Smye M, Nesbitt GS, Young I, Adgey AAJ. Diagnosis and risk stratification of patients with anginal pain and non-diagnostic electrocardiograms. Q J Med1999; 92:565–71.
9.
Newby DE, Fox KAA, Flint LL, Boon NA. A ‘same-day’ direct access chest pain clinic: improved management and reduced hospitalization. Q J Med1998; 91:333–7.
10. Gandhi MM, Lampe F, Wood DA. Management of angina pectoris in general practice, a questionnaire survey of general practitioners. Br J Gen Pract1995; 45:11–13.[Web of Science][Medline]
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