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 Chext 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

Who to Refer

*****November 2023 update. The RACP Clinics are under considerable pressure and can only see patients who meet the referral criteria. They kindly request that referrers check the criteria below before referral and use the RACPC proforma to ensure that only appropriate patients are referred.*****

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

• recent onset chest pain that you are concerned has a cardiac cause and where acute admission is not indicated.
• known ischaemic heart disease with recent onset or change in chest pains thought to be angina.

Exclusions

Please do not refer other urgent patients via this route as these clinics are not set up to deal with them appropriately:

• Patients with Acute MI 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 with 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*.

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

Acute Coronary Syndrome

Patients with suspected Acute coronary syndrome (unstable angina or acute myocardial infarction) should be sent immediately to hospital to confirm the diagnosis.

Suspect acute coronary syndrome, if:

• Pain in the chest or other areas (for example the arms, back, or jaw) lasts longer than 15 minutes.
• Chest pain is:
  • Associated with nausea and vomiting, sweating or breathlessness, or a combination of these.
  • Associated with haemodynamic instability (for example the person has a systolic blood pressure less than 90 mmHg).
  • Of a new-onset, or is the result of an abrupt deterioration of stable angina; with pain occurring frequently with little or no exertion, and often lasting longer than 15 minutes.

• Do not use the person's response to glyceryl trinitrate to confirm or exclude a diagnosis of acute coronary syndrome.

Immediate assessment in hospital is required if the patient:

• has current chest pain
• has signs of complications (such as pulmonary oedema).
• is pain-free, but has had chest pain in the last 12 hours and has an abnormal electrocardiogram (ECG) or an ECG is not available. 
• has a recent history of ACS, who have developed further chest pain

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.

*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.

What to do before referral

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

• Pulse - rate and rhythm
• Blood pressure
• Heart sounds

The following investigations should be considered:

• ECG  - An ECG should be done as soon as possible after presentation (2) but should not delay referral. It does not give a definitive diagnosis of angina, but provides information on heart rhythm and identifies signs of myocardial ischaemia, hypertrophy, and previous myocardial infarction. An ECG should be provided if available when referring to a Rapid Access Chest Pain Clinic. 
• Bloods  - Consider taking bloods at time of referral for FBC, glucose or HbA1c, lipid profile, U and E, TFT, LFT, CRP or provide recent results if these are available. Do not delay referral to await results.
• Chest X-ray — Consider requesting a CXR if there is suspected heart failure or pulmonary pathology (including pleural effusion, lobar collapse, lung cancer). Do not routinely request a chest X-ray for people with angina. 
• Echocardiogram - this is  not a requirement for referral to RACPC but please include results if this has been done previously.

Referrals

Referrals should be uploaded directly (not via referral service*) to one of the Rapid Access Chest Pain Clinics via e-RS. Use of the the BNSSG RACP referral form is recommended but not mandatory (should be available on your EMIS system). However, please include the required information in a referral to assist the cardiology teams in their triage and assessment processes. *Referrals should not be sent via the referral service as this may cause a delay. 

Please send an ECG with the Rapid Access Chest Pain Clinical referral if it has already been done, but do not delay referral awaiting result.

Patients should be advised that they will be contacted by telephone or post and should book their appointment as soon as possible. Please ensure up to date contact details are given on the referral. 

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.