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

ABSTRACT

At least 5% of GP and accident and emergency (A&E) attendances are undifferentiated chest pain. Rapid access chest pain clinics (RACPC) offer urgent guideline-directed management of suspected cardiac chest pain. The National Institute for Health and Care Excellence (NICE) recommends computed tomography coronary angiography (CTCA) as a first-line investigation. We evaluated the effectiveness and efficiency of a local RACPC. Retrospective analysis of unselected referrals to a RACPC in the Northeast of England was conducted for 2021. Baseline demographics and major adverse cardiovascular events (MACE) were compared between typical, atypical and non-angina. Anatomical and functional imaging results were recorded. Backward stepwise binary logistic regression modelled obstructive coronary artery disease (CAD) incidence. There were 373/401 (93.0%) patients with chest pain; 139 (37.3%) typical angina, 122 (32.8%) atypical angina and 112 (30.0%) non-angina. Typical angina patients were older (p<0.001) with more cardiovascular risk factors (p<0.001) and increased risk of obstructive CAD (adjusted odds ratio [OR] 6.27, 95% confidence interval [CI] 2.93 to 13.38) and MACE (9.4%, p=0.029). In total, 164 (44.0%) had invasive coronary angiography (ICA) within 7.4 ± 4.8 weeks; 19.5% had normal coronary arteries, 26.2% had obstructive CAD and 22.6% proceeded to invasive haemodynamic assessment ± PCI without major procedural complications. There were 39 (10.5%) who had CTCA within 34.6 ± 18.1 weeks; 25.6% needed ICA to clarify diagnosis. In conclusion, typical angina patients were at heightened risk of cardiovascular events. In the absence of adequate CTCA capacity, greater reliance on ICA still facilitated accurate diagnosis with options for immediate revascularisation, timely and safely, in the right patients. Better risk stratification and expansion of non-invasive imaging can improve local RACPC service delivery in the wider Northeast cardiology network.