Rapid Access Chest Pain Clinics

Overview

******Patients with suspected ACS and/or significant ecg changes at presentation should not be referred to RACPC. Call 999 and admit to hospital for immediate assessment******.

Rapid Access Chest Pain Clinics (RACPC) within BNSSG can be found at:

• Bristol Heart Institute (UHBW)
• Weston General Hospital (UHBW)
• Southmead Hospital (NBT)

The initial aim of assessment of a patient with chest pain is to identify, or exclude a serious cause which needs immediate hospital admission, such as acute coronary syndrome (see red flags below).

If hospital admission is not required then a detailed history and examination should be undertaken and an ecg performed. Other investigations should be carried out based on suspected cause.

Please also see the following guidelines:

• CKS guidance on Chest Pain
• CKS guidance on Angina

Purpose of RACPC

The RACPC provides a face-to-face clinic, led by a team of specialist nurses (some are non-medical prescribers), and occasionally doctors. The purpose of the service is to provide rapid assessment of patients with suspected stable cardiac chest pain (e.g. angina or atypical angina). They aim to support early diagnosis and management and identify those who may benefit from urgent investigation, treatment and intervention to prevent myocardial injury.

They also see recurrent/worsening angina symptoms in known ischaemic heart disease patients who have been medically optimised by primary care and are not under follow up by a cardiologist.

Please note: 

• NBT - There are no follow-up or optimisation clinics at Southmead (NBT).

• UHBW - may offer a second telephone RACPC follow-up appointment at clinicians’ discretion and WGH can also book into these clinics.

Who to Refer

Referrals to a Rapid Access Chest Pain Clinic should be reserved for patients with:

• Recent onset chest pain suspected to be of cardiac origin.
• No indication for acute admission.
• Known IHD with new or changing chest pain, not under active cardiology care.

⚠️ RACPCs are under significant pressure. Please use the BNSSG RACP referral form (template available in EMIS) and check the criteria carefully.

Exclusions

Please do not refer the following patients to RACPC:

• Suspected ACS or unstable angina - refer to Emergency Department and/or contact weekday IUC Professional line (see red flags). For IUC professional line please find link here.
• Patients under 30 years old (unless clear exertional symptoms or strong risk factors).
• Breathlessness without chest pain and no diabetes – consider other causes and BNP testing.
• Lone palpitations – refer to Electrophysiology (UHBW) or General Cardiology (NBT).
• Suspected valvular disease – request echo and refer to general or structural cardiology.
• Suspected heart failure – do BNP and refer to the Heart Failure Team.
• Patients actively under cardiology care.
• Congenital heart disease – refer to ACHD clinic at UHBW.
• Suspected pericarditis/myocarditis – refer to SDEC or use cardiology A&G.
• Patients currently under RACPC or cardiology investigation for CAD.
• Previously assessed for CAD within 12 months with documented medical management.
• Asymptomatic coronary calcification on CT – manage with primary prevention only. See Coronary Artery Calcification
• Significant anaemia – treat first, then reassess chest pain.
• One isolated, troponin-negative episode of chest pain at rest with no exertional component.
• Non-cardiac chest pain – consider alternative diagnosis or use appropriate advice and guidance.

Alternative referral pathways

RACPC should not be used for the rapid assessment of breathlessness or palpitations in the absence of chest pain. Please see below for alternative outpatient clinics:

Red Flags

Patients with suspected ACS and/or significant ecg changes at presentation should not be referred to RACPC. Call 999 and admit to hospital for immediate assessment*.

Refer immediately to hospital (via 999) if any of the following are present:

• Chest pain lasting >15 minutes, radiating to arms/back/jaw.
• Associated sweating, nausea, vomiting, or breathlessness.
• Hypotension (SBP < 90 mmHg).
• New or worsening chest pain occurring at rest or with minimal exertion.
• Recent chest pain (within 12 hrs) and abnormal ECG or no ECG available.
• Signs of complications (e.g. pulmonary oedema).
• Recent ACS history and further concerning cardiac sounding symptoms

👉 Response to GTN should not be used to rule in/out ACS.

CKS has advice on Which People With Chest Pain Should Be Admitted to Hospital: Scenario: Management | Management | Chest pain | CKS | NICE

Immediate Assessment

If a patient presents in general practice with current or recent history (within previous 12 hours) of chest pain suspected to be due to ACS, then call 999. Take an ECG if this is possible.

If the ECG excludes STEMI then during normal working hours, please also call the Weekday IUC Professional line on 0117 2449283 (open Monday to Friday 08:00 - 18:30  - not weekends and bank holidays) as patients without STEMI can often be managed as medically expected which helps streamline their route through the hospital.

Other causes of chest pain

Other indications for immediate admission to hospital can be found in the Management of Chest Pain section of the CKS guidelines.

What to do before referral

Patients should have a physical examination of their cardiovascular system and findings should be included in the referral including:

• Pulse rate and rhythm
• Blood pressure
• Heart sounds

The following investigations should be considered (but should not delay referral)

• ECG – ideally at presentation. Include with referral if available. AN ecg does not give a definitive diagnosis of angina, but can provide information on heart rhythm, signs of myocardial ischaemia, hypertrophy, and previous myocardial infarction. 
• Bloods – FBC, glucose/HbA1c, lipids, U&E, LFT, TFT, CRP (include results if available).
• Chest X-ray – only request if suspected heart failure or pulmonary cause. Do not routinely request a chest X-ray for people with suspected angina.

Echocardiogram – this is  not a requirement for referral to RACPC but please include results if this has been done previously.

Referrals

Upload referrals directly via e-RS to RACPC at your chosen site (do not use the Referral Service – delays may occur).

Use the BNSSG RACP referral form  (available as a template in EMIS). It's use is not mandatory,  however if not used please ensure the required information is included in a referral to assist the cardiology teams in their triage and assessment processes

Include:

• Full clinical history
• Relevant examination findings
• ECG (if done)
• Any relevant investigation results
• Up-to-date patient contact details

📞 Patients will be contacted to arrange their appointment – ensure their contact information is current.

❗If a referral is rejected, you’ll receive a notification via e-RS.

Contact details for urgent additional queries:

• BHI - contact on call cardiology registrar via switch.
• Weston - please contact the Cardiology Department on 01934 647030 or email: wnt-tr.racpcweston@nhs.net
• NBT - contact on call cardiology registrar via switch.

Referrals to RUH Bath

RUH Bath also has a RACPC although referral criteria may differ. 

Refer via eRS using the RUH RACP referral form available on the RUH website and in EMIS. Please submit directly via eRS and not via the Referral Service.

Resources

(1) Chest pain | Health topics A to Z | CKS | NICE

(2) Angina | Health topics A to Z | CKS | NICE

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.