A Rapid Access Chest Pain Clinic (RACPC): Initial Australian Experience.

BACKGROUND: Chest pain is the second most common presenting symptom to emergency departments (ED) in Australia, although up to 85% of these patients do not have an acute coronary syndrome (ACS). Cardiologist-led rapid access chest pain clinics (RACPC) have been proposed overseas to assist in the management of such patients, with prompt outpatient assessment if patients are deemed low risk and discharged from the ED. The use of RACPCs in Australia has been only recently proposed; we therefore sought to examine one such RACPC in an Australian context. METHODS AND RESULTS: 1133 consecutive patients were seen at a metropolitan RACPC, between August 2008 and February 2017. There was a high preponderance of cardiovascular risk factors. Exercise stress testing (EST) was the default investigation upon discharge from ED, with a total of 1038 ESTs performed in 1113 patients (93%), with low numbers of other functional tests, and a small, but increasing number of coronary computed tomography (CT) scans performed over this period. Eighteen patients subsequently underwent revascularisation (1.6% of the total cohort), and none of these patients were readmitted at any time with an ACS between the interval of their index ED presentation to these investigations or treatments. Five (0.4%) patients represented to ED within 48hours, none due to a cardiovascular cause. A total of 24 (2.1%) patients represented between 2 and 28 days, with none of these due to an ACS. CONCLUSIONS: Following ED assessment of acute chest pain as low risk-with direct ED referral for exercising testing followed by RACPC review-results in very low readmission rates at 48hours and at 28 days. Moreover, these readmissions were almost always not of cardiovascular aetiology, and occurred despite relatively longer waiting periods for both EST (8 days) and between EST and RACPC review (11 days), than the prespecified 72 to 96hours as defined by the clinic protocol. Further investigation into this model of care in Australia is suggested.

A Comparison of Image Quality Using Radial vs Femoral Approaches in Patients Undergoing Diagnostic Coronary Angiography.

INTRODUCTION: Radial access for diagnostic coronary angiography (CAG) has gained traction in recent years over the femoral artery approach, but difference in image quality has not been extensively studied. This study aims to compare image quality and diagnostic value in radial vs femoral access in patients undergoing invasive CAG. METHODS: This is a retrospective study of 200 patients (100 radial and 100 femoral) undergoing CAG at an experienced center from 2014 to 2015. The primary endpoint was angiographic image quality, and secondary endpoints were proportion of non-diagnostic images and patient radiation dose. Image quality was assessed by four experienced angiographers using a quantitative scale. Mean differences in scores were compared as well as proportion of non-diagnostic images produced. RESULTS: Radial access produced images that were significantly poorer than femoral access when viewing the left coronary artery (2.65 ± 0.04 vs 2.79 ± 0.03; P<.01). This difference remained significant after adjusting for age, gender, and catheter size (P=.04). There was no significant difference in image quality between the radial and femoral group when viewing the right coronary artery (2.91 ± 0.03 vs 2.84 ± 0.04; P=.11). There was a higher proportion of non-diagnostic images produced by radial access than femoral (3.23% vs 2.02%; P<.01) and radial access resulted in higher patient radiation doses (832.81 ± 49.59 mGy vs 645.69 ± 35.46 mGy; P<.01). CONCLUSION: Radial access produces poorer angiographic image quality and exposes patients to greater radiation compared to femoral access in contemporary practice. An awareness of these limitations is important when selecting mode of access in patients undergoing diagnostic CAG.