Update Cardiac Chest Pain Pathways at NUH

1. Update Cardiac Chest Pain Pathways at NUH Dr John Walsh Delivered by Dr Alun Harcombe 16/06/2015

2. Updating Cardiac Chest Pain Pathways at NUH • Chest pain • Current Pathways • Proposed Pathways • Main differences • Resource implications • Summary

3. Updating Cardiac Chest Pain Pathways at NUH • Chest pain • Current Pathways • Proposed Pathways • Main differences • Resource implications • Summary

4. Background - UK 1% of visits to GP because of chest pain Up to 40% emergency hospital admissions are because of chest pain Almost 2 million people have had angina

5. Why does difference matter? • Stable angina investigated as Out-Patient • Acute coronary syndromes (ACS) as In-Patient (mortality benefit = urgent admission) • Unstable angina • Non-ST elevation MI • ST elevation MI

6. All chest pain is Cardiac until proven otherwise

7. Cardiac Chest Pain Service

8. Investigation of stable angina • History and physical examination (90%) • ETT now only in those with known CAD • Test for ischaemia/evidence coronary disease • Non-invasive or ‘Functional’ Imaging • Dobutamine stress echocardiogram (DSE) • Myocardial perfusion scan (MPS or MPI) • Invasive • Coronary angiography (Gold Standard)

9. New diagnostic tests • CT Coronary calcium score • Quick, low radiation, easy • Nuclear medicine can do • 25 to 50% patients having calcium score may need: • CT coronary angiography (multi-slice CT) • Slower, higher radiation, resolution not as good as coronary angiography (yet) • Done in radiology

10. Updating Cardiac Chest Pain Pathways at NUH • Chest pain • Current Pathways • Proposed pathways • Main differences • Resource implications • Summary

11. STEMI Activate PPCI Pathway NSTEMI/UA 3 Day ACS Pathway Non-cardiac Chest Pain Recent Onset Stable Angina RACPC Cannot exclude Cardiac Cause - GP Chest Pain of Recent Onset - now PPCI Team TCC 440 cases/year ACS Nurse Specialist, CATS, QMC Cardiologist 600 PCI cases/year ED/Medicine advise GP to refer to cardiology OP 400 elective PCI/year

12. Updating Cardiac Chest Pain Pathways at NUH • Chest pain • Current Pathways • Proposed pathways • Main differences • Resource implications • Summary

13. Key Drivers • Need for clear Chest Pain Pathway • NICE CG 95 • Re-admission reduction • Reduce IP length of stay • Harmonise disparate referral routes • Bring diagnosis forward in pathway

14. Its all about riskNICE CG 95 CAD Prediction

15. Clinical JudgementFeatures of stable angina • Constricting discomfort in the front of the chest, neck, shoulders, jaw or arms • Precipitated by physical exertion • Relieved by rest or GTN in about 5 minutes People with – • Non-anginal chest pain have one / none of these • Atypical angina: two features • Typical angina: all three features

16. STEMI Activate PPCI Pathway Non-cardiac NSTEMI/UA 3 Day ACS Pathway Chest Pain Recent Onset Stable Angina Chest Pain Service Cannot exclude Cardiac Cause CCPS Chest Pain of Recent Onset - Aim PPCI Team TCC ACS Nurse Specialist, CATS, QMC Cardiologist Pathway or D/C determined by clinical impression *Cardiac Chest Pain Service QMC (IP) or City (OP) *Cardiac Chest Pain Service QMC (IP) or City (OP) NICE CG95 Chest Pain of Recent Onset NICE CG94 Unstable angina and NSTEMI: the early management of unstable angina and non-STEMI, STEMI guideline to be updated July 2013. * = New post or new service

17. Updating Cardiac Chest Pain Pathways at NUH • Chest pain • Current Pathways • Proposed pathways • Main differences • Resource implications • Summary

18. Updated service • RACPC becomes Cardiac Chest Pain Service • DSE and MPS specialist nurses move to CCPS • Nurse Specialist at QMC for Chest Pain of Recent Onset - alongside ACS Nurse • Expand CATS nursing team at QMC • Referral to single service regardless of GP, ED, Acute Medicine or other source • Electronic referral • Patients get same care at same time by same team regardless of presentation

19. Benefits • Chest pain referrals to Cardiology if reasonable suspicion of cardiac cause, or cardiac cause cannot be excluded. • New Out-Patient ‘Chest Pain Service’ mandated by NICE CG95 to which stable angina and unclear diagnosis patients can be referred. • Cardiology organise, review and report all tests relieving other colleagues of follow up or review of results. • Pool of specialist nurses re-focused to smooth pathway.

20. Updating Cardiac Chest Pain Pathways at NUH • Chest pain • Current Pathways • Proposed pathways • Main differences • Resource implications • Summary

21. Summary • Patients with Chest pain of recent onset can be referred to In-Patient or Out-Patient Cardiac Chest Pain Service (CCPS) • CCPS Nurse Led, Consultant Supervised • Clearly defined pathways for all groups may reduce admissions/re-admissions • Non-cardiac chest pain (or non-specific chest pain) will not require further cardiology input once reviewed and identified as such • Resource implications -staff and diagnostics – some savings possible

22. UpdateGP pathway • Mirrors NUH chest pain process • Risk prediction required • ? Improves primary prevention • Guidance -who and when to refer • Choose and Book referral • Electronic desktop guidance • CPS service replaces RACPC • Pts investigation and plan within 4/52 • May be scope for rapid speciality assessment service in future for pts with pain in preceding 3/7- but lets walk before we run !

23. Chest pain made easy The Cardiac Cascade • 1 - Cardiac or Non-Cardiac • 2 - Non-cardiac – Reassure • 3 – Stable or Unstable • 4 – Unstable – admit • 5 – Stable Cardiac Diagnosis (Known) - Treat and/or refer • 6 – Stable Cardiac Diagnosis (Unknown) - Predict, treat and/or refer • 7 - Predict - <10%- Reassure/discharge - 10-60% - ? Treat and refer - 60-90% - Treat and refer - 90% - Treat and review • 8 - Cardiac Prognosis - Diagnosis confirmed but ongoing symptoms-Refer

24. NUH Cardiology CAD likelihood assessment tool for Chest Pain Recent Onset Primary Care Referral Guidance to NUH Chest Pain Service (CPS) 3 3 Chest Pain Referral from GP to Chest Pain Service (CPS) Clinic visit 1 -all referrals to be reviewed within 2 weeks Clinic visit 2 - all investigations completed within 4 weeks Symptomatic patients and/or those with positive investigations to be reviewed once in nurse lead clinic – subsequent follow up agreed with responsible consultant/SpR Asymptomatic patients and/or those with negative investigations contacted by telephone and if necessary offered clinic review

25. Chest pain – Cardiac or not ?

26. When to refer

29. CPS - Process Chest Pain Referral from GP to Chest Pain Service (CPS) Clinic visit 1 -all referrals to be reviewed within 2 weeks Clinic visit 2 - all investigations completed within 4 weeks Symptomatic patients and/or those with positive investigations to be reviewed once in nurse lead clinic – subsequent follow up agreed with responsible consultant/SpR Asymptomatic patients and/or those with negative investigations contacted by telephone and if necessary offered clinic review

30. UpdateACS pathway • Baseline/3 hr troponin • More rapid assessment/pt discharge • Risk assessment to streamline pts to NCH (high) or QMC campus (low) – defined discharge plan • Standardised treatment • Non ACS but cardiac pain – clear management plan/electronic referral (NOT GP TO DO!) • Non-ACS pts not expected to wait specialist review • Standardised GP/pt letter

31. NUH ACS pathway Use in all patients aged >24 years unless : -No chest pain past 72 hrs -Clearly stable angina -Clearly noncardiac -Suspect oesophageal rupture, aortic dissection, PE. REFER NCH URGENTLY FOR STEMI/NEW LBBB 2 Always use clinical judgment in managing individual patients * *on admission • NSTEMI management • Calculate ‘NSTEMI GRACE’ risk (see box 3) • Refer CATS team – if unavailable within 15 mins bleep cardiology ‘SpR’ at QMC or NCH or call Cisco Phone -70090/70091 • Contact ACU NCH 56213or CCU QMC 69055 direct if necessary ① Assessment by ② Senior sign-off by (quality indicator; consultant if present, ST4-6 if not) ① ② Print name Signature Position Date Time

32. For link to online calculator click on any ED shop floor PC and look in ‘ED favorites’ folder For ED ‘Acute chest pain: NSTEMI rule in/out’ tool (this document) Box ➂ ‘NSTEMI GRACE’ risk

33. NUH ED/Acute medicine CAD predictive assessment tool To be used following ACS rule-out to enable appropriate planning of further management Do not use if raised cTnI or acutely ischemic ECG Always use clinical judgement in managing individual patients 3 * *on admission ① Assessment by ② Senior sign-off by (consultant, substantive ST4-6 or cardiac nurse/reg) ① ② Print name Signature Position Date Time

34. Chest pain – Cardiac or not ?

35. Heart Score

37. Emergency/Acute Medicine Department Nottingham University Hospitals Trust Queens Medical Centre Campus Derby Road Nottingham NG7 2UH EDU desk EDU fax 0115 xxxxxxxxx 0115 xxxxxxxxx Date Dear Doctor, Your patient attended our ED/acute Medical Unit with chest pain of recent onset. History in one single sentence: We have excluded an acute coronary syndrome (ACS) using a validated rule-out protocol.[1] Suggested further management (EDU/Acute medicine) clinician please tick the statement(s) below as applicable) We have assessed the likelihood that your patient has symptomatic coronary artery disease (CAD), using an approach recommended by NICE (see pathway on reverse). [2] Our suggestions for further management are as followed: • Your patient has an established diagnosis of CAD (see box 1 on reverse for details)… • … and reports typical anginal pain – continue / optimize treatment for stable angina as recommended by NICE.[3] • … but we are not certain that your patients chest pain is caused by CAD. Consider (re-)referral for diagnostic testing. • CAD is <10% likely and diagnostic testing is not required. Consider other causes of chest pain (e.g. gastrointestinal and musculoskeletal conditions) when reviewing the patient. • CAD is <10% likely but your patient reports typical anginal pain. Testing for CAD is not indicated but consider referral to a cardiologist to look for non-CAD causes of angina (such as hypertrophic cardiomyopathy or syndrome X). • CAD is between 10 and 60% likely (see box 5 on reverse for more details). We have/have not (circle as appropriate) yet started anti-anginal therapy and referred your patient to the Chest Pain Service (CPS) for further investigation. • CAD is between 61 and 90% likely (see box 5 for more details). We have started your patient on antianginal therapy and referred your patient to the Chest Pain Service (CPS) for further investigation. • NB: Further recommendations for patients in whom the results of CAD diagnostic testing is awaited (as indicated): • Your patient requires appropriate management for anaemia (Hb < 13g/dL in men; <12g/dL in women); Hb: _____ g/dL • Your patient reports typical anginal pain and should be managed as stable angina as recommended by NICE.[3] • Your patient reports typical anginal pain and CAD is >90% likely. We have referred him / her for follow-up within 4/52 to the Acute Coronary Syndrome nurse. We recommend treatment for stable angina as per NICE guidance.[3] • Your patient is very frail and unlikely to benefit from a standard management approach. Consider an individualized care plan. Further suggestions (if applicable): References 1. HammCW, BassandJP, AgewallS et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2011;32:2999-3054. • National Institute for Health and Clinical Excellence. Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin (clinical guideline 95). 2010. www.nice.org.uk/guidance/CG95 • National Institute for Health and Clinical Excellence. Management of stable angina (clinical guideline 126). 2011. www.nice.org.uk/guidance/CG126 Please do not hesitate to contact myself or ED consultant if you have questions about our management of this case. EDU Clinician Print Name Signature Role

38. Chest pain made easy The Cardiac Cascade • 1 - Cardiac or Non-Cardiac • 2 - Non-cardiac – Reassure • 3 – Stable or Unstable • 4 – Unstable – admit • 5 – Stable Cardiac Diagnosis (Known) - Treat and/or refer • 6 – Stable Cardiac Diagnosis (Unknown) - Predict, treat and/or refer • 7 - Predict - <10%- Reassure/discharge - 10-60% - ? Treat and refer - 60-90% - Treat and refer - 90% - Treat and review • 8 - Cardiac Prognosis - Diagnosis confirmed but ongoing symptoms-Refer

39. Lets not go there !

40. Actual Ca score-300 CT angiography - 150 DSE – 400 MPI– 400 Angio -375 (assumes angio/functional imagingI 50/50 and DSE/MPI 50/50 split and angio or medication 50% treated medically ) Increase Ca score-300 CT angiography- 150 DSE - 175 MPI – 175 Angio -275 (assumes angio/functional imagingI 50/50 and DSE/MPI 50/50 split and angio or medication 50% treated medically ) Annual Workload EstimateDepartment