Q J Med 2001; 94: 177-178
© 2001 Association of Physicians
Editorial |
Rapid cardiology—for chest pain, breathlessness and palpitations
National Heart and Lung Institute at the Charing Cross Campus, Hammersmith Hospital NHS Trust, Imperial College School of Medicine Imperial College of Science, Technology and Medicine, London
Rapid assessment of cardiac chest pain by a specialist is soon to become the norm, changing traditional referral practices for diagnosis and management of angina pectoris in the community.1 Patients presenting to general practitioners with chest pain considered to be exertional angina, will be assessed quickly through the Rapid Access Chest Pain Clinics (RACPCs) rolling out nationwide; at least 50 this year and 100 by April 2002.2 Those with symptoms suggestive of acute coronary disease will still be sent directly to Casualty, preferably by ambulance. If hospital admission is not required, patients with symptoms of angina can then be directly referred to the RACPC, rather than given a traditional out-patient appointment or sent back to their general practitioner without any form of specialist assessment. These RACPCs will thus close the loop between community and hospital for chest pain assessment. Whatever the point of first medical contact, general practitioner or casualty, all patients with their first presentation of exertional angina could ultimately be reviewed in a RACPC—conservatively estimated to be about 22600 consultations per annum in the UK.3
The rationale for rapid assessment of angina is simple: cardiac chest pain is common, frightening for the patient and worrying for the GP or casualty officer. Coronary artery disease can lead to substantial morbidity and mortality—progression to unstable angina, myocardial infarction or death. These life-threatening complications can all occur in the short term, within days or weeks of medical presentation.3,4 Patients at high risk, with evidence of significant reversible ischaemia, can be quickly identified at the point of presentation.5 Since treatments are available which can relieve symptoms and improve prognosis—aspirin, statins, ACE inhibitors and revascularization—it is likely that this disease's natural history can be improved. Care organized through RACPCs should reduce unnecessary hospitalization, and allow treatments to be delivered by clinical priority to high-risk patients, thus improving overall patient management.6 Public expectations from such a rapid service would be that patients are correctly diagnosed, risk stratified and appropriately managed in a timely way, with symptoms consequently being eased, or completely relieved, and the immediate risk of further morbidity or mortality reduced. For the many patients in the community with chest pain that is not cardiac in origin, RACPCs can swiftly provide appropriate reassurance.
A number of observational studies support the utility of RACPCs.5–7 These follow-up (up to 1 year) studies of patients assessed through a RACPC consistently show effective risk stratification, reduced hospitalization, very low rates of coronary events in patients discharged as ‘non-cardiac pain’, and high rates of satisfaction with the service. So far, no randomized controlled trial has compared a RACPC with traditional care pathways, and so it is not known whether this new approach reduces coronary morbidity and mortality. Such a trial is now unlikely to occur, because RACPCs are now becoming a standard part of the district cardiology service. However, this constraint does not apply to the evaluation of this model of care for other cardiac symptoms.
If this rationale justifies rapid assessment of chest pain, why not offer rapid services for patients presenting with breathlessness due to heart failure, or palpitation caused by tachy/brady arrhythmias? About a third of patients presenting for the first time with heart failure do so to their general practitioner.8 Diagnosing this clinical syndrome, and defining its aetiology, can often be quite difficult in the absence of specialist investigations.9 These patients, who mostly have coronary disease,10 are at very high risk. Short-term prognosis for new cases of heart failure is poor, with 43% dying within 18months of medical diagnosis.11 There are medical and surgical treatments (ACE inhibitors, ß-blockers, spironolactone, and revascularization), which improve the natural history of this clinical syndrome.12 So should we not offer the same rapid access to specialist care that we are now offering chest pain patients to those presenting for the first time with heart failure?13
Similarly, palpitation is a common symptom of potentially serious tachy/brady arrhythmias. Atrial fibrillation is the commonest arrhythmia, which can lead in the short term to disabling stroke or heart failure.14 Chemical or electrical cardioversion and anticoagulation can reduce the risk of these serious complications.14 Early diagnosis increases the chances of restoring sinus rhythm, including the use of immediate cardioversion without prior anticoagulation.15 Anticoagulation in selected patients can protect against embolic complications, and so logically should be started as soon as possible after the onset of atrial fibrillation.14 Rapid diagnosis could therefore also modify the natural history of atrial fibrillation, as well as other life-threatening arrhythmias, by using appropriate treatments with proven efficacy: DC cardioversion, anti-arrhythmic therapies, ablative therapy, pacemaker implantation and the implantable defibrillator.16
With the exception of a ‘heart attack’, cardiac diseases are not as emotive to patients as cancer. Yet exertional angina at the point of first presentation, heart failure and some tachy/brady arrhythmias are all life-threatening and, depending on the underlying pathology, can have a poorer short term prognosis than many cancers. Rapid specialist assessment of common cardiac symptoms—chest pain, breathlessness and palpitations—has the potential to quickly resolve the patient's diagnosis, stratify risk and lead to timely treatments of proven efficacy. Rapid cardiology could substantially replace the traditional interface between primary and secondary care. The present choice for the general practitioner is Casualty or an out-patient appointment, the latter often frustratingly arranged for many weeks or months after the patient's initial medical presentation. In this waiting period, patients are not always receiving evidence-based therapies and can quickly come to grief. The alternative of rapid cardiological assessment should be developed and evaluated by randomized controlled trials. Rapid cardiac assessment could transform the face of cardiology for general practitioners and patients and further reduce the morbidity and mortality of common cardiac diseases in the community.
References
1. The National Service Framework for Coronary Heart Disease. HMSO, 2000.
2. Timmis AD. Speeding up cardiac care. Impact1999; 1:1–3.
3.
Gandhi MM. Incidence, clinical characteristics, and short-term prognosis of angina pectoris. Br Heart J1995; 73:193–8.
4. Duncan B, Fulton M, Morrison SL, Lutz W, Donald KW, Kerr F, Kirby BJ, Julian DG, Oliver MF. Prognosis of new and worsening angina pectoris. Br Med J1976; 1:981–5.
5. Jain D, Fluck D, Sayer RW, Ray S, Paul EA, Timmis AD. A One-stop chest pain clinic can identify high cardiac risk. J Roy Coll Phys1997; 31:401–4.
6.
Davie AP, Caesar D, Caruana L, Clegg G, Spiller J, Capewell S, et al. Outcome from a rapid assessment chest pain clinic. Q J Med1998; 91:339–43.
7.
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.
8.
Cowie MR, Wood DA, Coats AJ, Thompson SG, Poole-Wilson PA, Suresh V, Sutton GC. Incidence and aetiology of heart failure a population-based study. Eur Heart J1999; 20:421–8.
9.
The Task Force on Heart Failure of the European Society of Cardiology. Guidelines for the diagnosis of heart failure. Eur Heart J1995; 16:741–51.
10. Fox KF, Cowie MR, Wood DA, Coats AJS, Gibbs JSR, Underwood SR, Turner RM, Poole-Wilson PA, Sutton GC. Coronary artery disease as the cause of incident heart failure in the population. Eur Heart J2001; 22:28–36.
11.
Cowie MR, Wood DA, Coats AJ, Thompson SG, Suresh V, Poole-Wilson PA, Sutton GC. Survival of patients with a new diagnosis of heart failure: a population based study. Heart2000; 83:505–10.
12. Scottish Intercollegiate Guidelines Network. Diagnosis and treatment of heart failure due to left ventricular systolic dysfunction. SIGN Publication no 35, Feb 1999.
13. Fox KF, Cowie MR, Wood DA, Coats AJ, Poole-Wilson PA, Sutton GC. A Rapid Access Heart Failure Clinic promptly identifies heart failure and initiates appropriate therapy. Eur J Heart Failure2000; 2:423–9.[Web of Science][Medline]
14.
Levy S, Breithardt G, Campbell RW, Camm AJ, Daubert J-C, et al. Atrial fibrillation: current knowledge and recommendations for management. Eur Heart J1998; 19:1294–320.
15.
Prystowsky EN, Benson DW, Fuster V, Hart R, Kay GN, Myeburg RJ, Naccarelli GV, Wyse DG. Management of Patients with Atrial Fibrillation. Circulation1996; 93:1262–77.
16.
Gregoratos G, Cheitlin MD, Conill A, Epstein AE, Fellows C, Ferguson TB, et al. ACC/AHA Guidelines for the Implantation of Cardiac pacemakers and Antiarrhythmia Devices: Executive Summary. Circulation1998; 97:1325–35.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  J.P. Dougan, T.P. Mathew, J.W. Riddell, M.S. Spence, P.G. McGlinchey, G.S. Nesbitt, M. Smye, I.B.A. Menown, and A.A.J. Adgey Suspected angina pectoris: a rapid-access chest pain clinic QJM, December 1, 2001; 94(12): 679 - 686. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||