Hesse Kerrick, Htet Zaw, Jachuck Mickey, Jenkins Nicholas
Cardiology Registrar (ST6).
Consultant Cardiologist.
Br J Cardiol. 2023 Sep 5;30(3):28. doi: 10.5837/bjc.2023.028. eCollection 2023.
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.
至少5%的全科医生诊疗及急诊就诊病例为不明原因的胸痛。快速胸痛诊所（RACPC）为疑似心脏性胸痛提供紧急的指南导向管理。英国国家卫生与临床优化研究所（NICE）推荐计算机断层扫描冠状动脉造影（CTCA）作为一线检查方法。我们评估了当地一家RACPC的有效性和效率。对2021年英格兰东北部一家RACPC未经选择的转诊病例进行了回顾性分析。比较了典型、非典型和非心绞痛患者的基线人口统计学特征和主要不良心血管事件（MACE）。记录了解剖学和功能成像结果。采用向后逐步二元逻辑回归模型分析阻塞性冠状动脉疾病（CAD）的发病率。共有373/401（93.0%）例胸痛患者；139例（37.3%）为典型心绞痛，122例（32.8%）为非典型心绞痛，112例（30.0%）为非心绞痛。典型心绞痛患者年龄较大（p<0.001），心血管危险因素较多（p<0.001），阻塞性CAD风险增加（调整优势比[OR]6.27，95%置信区间[CI]2.93至13.38）以及MACE风险增加（9.4%，p=0.029）。共有164例（44.0%）患者在7.4±4.8周内接受了有创冠状动脉造影（ICA）；19.5%的患者冠状动脉正常，26.2%的患者患有阻塞性CAD，22.6%的患者进行了有创血流动力学评估±PCI，无重大手术并发症。有39例（10.5%）患者在34.6±18.1周内接受了CTCA检查；25.6%的患者需要ICA来明确诊断。总之，典型心绞痛患者发生心血管事件的风险较高。在缺乏足够CTCA能力的情况下，更多地依赖ICA仍有助于准确诊断，并为合适的患者提供及时、安全的立即血运重建选择。更好的风险分层和无创成像的扩展可以改善更广泛的东北心脏病学网络中当地RACPC的服务提供。
